Top 10 Resources in Global Surgery

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.

Mobile technologies to support healthcare provider to healthcare provider communication and management of care

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.

The Role of the Orthopaedic Surgeon in the COVID-19 Era: Cautions and Perspectives

The current coronavirus disease 2019 (COVID-19) pandemic has revolutionized global healthcare in an unprecedented way and with unimaginable repercussions. Resource reallocation, socioeconomic confinement and reorganization of production activities are current challenges being faced both at the national and international levels, in a frame of uncertainty and fear. Hospitals have been restructured to provide the best care to COVID-19 patients while adopting preventive strategies not to spread the infection among healthcare providers and patients affected by other diseases. As a consequence, the concept of urgency and indications for elective treatments have been profoundly reshaped. In addition, several providers have been recruited in COVID-19 departments despite their original occupation, resulting in a profound rearrangement of both inpatient and outpatient care. Orthopaedic daily practice has been significantly affected by the pandemic. Surgical indications have been reformulated, with elective cases being promptly postponed and urgent interventions requiring exceptional attention, especially in suspected or COVID-19+ patients. This has made a strong impact on inpatient management, with the need of a dedicated staff, patient isolation and restrictive visiting hour policies. On the other hand, outpatient visits have been limited to reduce contacts between patients and the hospital personnel, with considerable consequences on post-operative quality of care and the human side of medical practice.

In this review, we aim to analyze the effect of the COVID-19 pandemic on the orthopaedic practice. Particular attention will be dedicated to opportune surgical indication, perioperative care and safe management of both inpatients and outpatients, also considering repercussions of the pandemic on resident education and ethical implications.

Education in ear and hearing care in remote or resource-constrained environments.

At the heart of surgical care needs to be the education and training of staff, particularly in the low-income and/or resource-poor setting. This is the primary means by which self-sufficiency and sustainability will ultimately be achieved. As such, training and education should be integrated into any surgical programme that is undertaken. Numerous resources are available to help provide such a goal, and an open approach to novel, inexpensive training methods is likely to be helpful in this type of setting.The need for appropriately trained audiologists in low-income countries is well recognised and clearly goes beyond providing support for ear surgery. However, where ear surgery is being undertaken, it is vital to have audiology services established in order to correctly assess patients requiring surgery, and to be able to assess and manage outcomes of surgery. The training requirements of the two specialties are therefore intimately linked.This article highlights various methods, resources and considerations, for both otolaryngology and audiology training, which should prove a useful resource to those undertaking and organising such education, and to those staff members receiving it.

Backward Planning a Craniomaxillofacial Trauma Curriculum for the Surgical Workforce in Low-Resource Settings.

Background
Trauma is a significant contributor to global disease, and low-income countries disproportionately shoulder this burden. Education and training are critical components in the effort to address the surgical workforce shortage. Educators can tailor training to a diverse background of health professionals in low-resource settings using competency-based curricula. We present a process for the development of a competency-based curriculum for low-resource settings in the context of craniomaxillofacial (CMF) trauma education.

Methods
CMF trauma surgeons representing 7 low-, middle-, and high-income countries conducted a standardized educational curriculum development program. Patient problems related to facial injuries were identified and ranked from highest to lowest morbidity. Higher morbidity problems were categorized into 4 modules with agreed upon competencies. Methods of delivery (lectures, case discussions, and practical exercises) were selected to optimize learning of each competency.

Results
A facial injuries educational curriculum (1.5 days event) was tailored to health professionals with diverse training backgrounds who care for CMF trauma patients in low-resource settings. A backward planned, competency-based curriculum was organized into four modules titled: acute (emergent), eye (periorbital injuries and sight preserving measures), mouth (dental injuries and fracture care), and soft tissue injury treatments. Four courses have been completed with pre- and post-course assessments completed.

Conclusions
Surgeons and educators from a diverse geographic background found the backward planning curriculum development method effective in creating a competency-based facial injuries (trauma) course for health professionals in low-resource settings, where contextual aspects of shortages of surgical capacity, equipment, and emergency transportation must be considered.

The ReSurge Global Training Program: A Model for Surgical Training and Capacity Building in Global Reconstructive Surgery.

A paradigm shift is underway in the world of humanitarian global surgery to address the large unmet need for reconstructive surgical services in low- and middle-income countries (LMICs). Here, we discuss the ReSurge Global Training Program (RGTP), a model for surgical training and capacity building in reconstructive surgery in the developing world. The program includes an online reconstructive surgery curriculum, visiting educator trips, expert reconstructive surgeon involvement, trainee competency tracking system, and identification of local outreach partners to provide safe reconstructive surgery to the neediest of patients in the developing world.A retrospective review of the components of the RGTP from July 2014 through June 2017 was performed. Trainee milestones scores were analyzed to observe trends toward competency in specific plastic surgery skill sets.There were a total of 38 visiting educator trips during the study period. The trips took place in 10 LMICs. A total of 149 trainees were evaluated in the context of the visiting educator trips with 377 distinct submodule evaluations. Four trainees had more than 10 submodule evaluations over 2 or more visiting educator trips. There was notable improvement in milestones ratings over time among the trainees in this program.The RGTP is a model of reconstructive surgical training and capacity building in LMICs. Trainees develop important skill sets in reconstructive surgery as a result of their involvement in the program. This comprehensive training approach addresses the disparity in access to care in the developing world by providing short- and long-term solutions to unmet reconstructive needs.

Health Care in Guatemala.

There are 10 hospitals with general surgery training programs in Guatemala. Of those 10 hospitals, only 3 are tertiary care hospitals, and all of these are located in Guatemala City. Two are part of the public health system and the other belongs to a semiprivate public health system. There are currently no colorectal training programs. If a Guatemalan surgeon wishes to pursue a career in coloproctology, he or she has to look for training opportunities abroad.

Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia.

Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda.

Background
The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty.

Methods
Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants’ responses.

Results
Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45).

Conclusions
General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.

BACKGROUND:
The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

METHODS:
The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

RESULTS:
Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

CONCLUSION:
Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.