A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures

Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear.
Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection.

Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various “late” time thresholds for debridement versus “early” thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n =18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement.

Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background
Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods
A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results
346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions
Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

A cohort study of differences in trauma outcomes between females and males at four Indian Urban Trauma Centers

Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database.
Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator.
Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality.
Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.

Drug shortages in low- and middle-income countries: Colombia as a case study

Background
Drug shortages are a global problem. Analyzing shortages worldwide is important to identify possible relationships between drug shortages across countries, determine strategies that reduce drug shortages, and reduce the inequality in access to medicines between countries. In contrast to well-documented shortages in high-income countries, there are few studies that consider low- and middle-income economies. We evaluate drug shortages in one middle-income country, Colombia.

Methods
We collected data from INVIMA, the institution responsible for managing medicine shortage alerts in Colombia. We classified the data using the Anatomical Therapeutic Chemical (ATC) classification system and analyzed them using descriptive statistics. We considered a study period from 2015 to 2021 (vital medicines) and from 2010 to 2020 (non-vital medicines).

Results
In total, 173 unique ATC codes were in shortage. These included antidotes, alimentary tract and metabolism products, anesthetics, cardiac stimulants and antithrombotic agents. The major causes were manufacturing problems and few suppliers. Drug shortages substantially increased from 2020 to May 2021 due to the COVID-19 pandemic. Among resolved shortages, the average duration was 1.6 years with a standard deviation of 1.9 years. The longest, naloxone tablets, were in shortage for almost 10 years.

Conclusions
Drug shortages are a persistent problem in Colombia. Government institutions have made progress in implementing systems and procedures to report them. However, the approaches implemented need to be maintained and refined. This study lays the groundwork for the analysis of drug shortages in other LMICs. We highlight the necessity of addressing drug shortages in their global context and reducing the inequality in access to medicines between countries.

Coaching for impact: successful implementation of a multi-national, multi-institutional synchronous research course in Ethiopia

Purpose
Under the American College of Surgeons’ Operation Giving Back, several US institutions collaborated with a teaching and regional referral hospital in Ethiopia to develop a surgical research curriculum.

Methods
A virtual, interactive, introductory research course which utilized a web-based classroom platform and live educational sessions via an online teleconferencing application was implemented. Surgical and public health faculty from the US and Ethiopia taught webinars and led breakout coaching sessions to facilitate participants’ project development. Both a pre-course needs assessment survey and a post-course participation survey were used to examine the impact of the course.

Results
Twenty participants were invited to participate in the course. Despite the majority of participants having connection issues (88%), 11 participants completed the course with an 83% average attendance rate. Ten participants successfully developed structured research proposals based on their local clinical needs.

Conclusion
This novel multi-institutional and multi-national research course design was successfully implemented and could serve as a template for greater development of research capacity building in the low- and middle-income country (LMIC) setting.

Safe and Standard Thyroid Cancer Surgery, or Lack Thereof: Patterns and Correlates of Patient Referral to Tertiary Care Centre for Revision Thyroid Surgery in a LMIC

Background A surgeon’s characteristics such as volume and practice setup are essential elements in outcome of thyroid cancer. However, little information is available from the developing world regarding qualities of primary surgeon, such as level of knowledge, skill, and proper documentation while referring to higher center.

Methods Records of 164 patients of differentiated thyroid cancer (DTC) from January 1990 to December 2018 undergoing revision thyroid surgery following primary surgery elsewhere were retrospectively analyzed.

Results Out of 164 patients with postoperative diagnosis of DTC, referral patterns were as follows: low volume (LV) to high volume (HV) (n = 120, 73.2%), followed by HV to HV (n = 44, 26.8%). The primary surgery assessed by the extent of residual disease was in agreement with the documentation in only 55%. The type of thyroidectomy performed was not mentioned in 9.8%. The status of the parathyroid glands was mentioned only in 15.8% and recurrent laryngeal nerve in 12.2%. Less than recommended surgery was performed in 52.5% patients. Despite less than recommended surgery, 44.5% patients were directly referred for radioactive iodine ablation (RAIA). Thirty two percent patients were referred for RAIA after hemithyroidectomy. Central or lateral compartment lymphadenectomy, even after indication, was less likely at LV centers (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.64–0.77). Similarly, for DTC patients, the relationship between LV center surgery and subsequent referral for RAIA was RR, 0.71 (95% CI, 0.48–1.02).

Conclusions Most patients referred from LV surgeons are less likely to have proper thyroidectomy, have inadequate documentation of the primary surgery, and are referred for RAIA after less than total thyroidectomy. Our study highlights the lacunae in the approach to and understanding of thyroid cancer surgery by secondary care physicians in our country. We believe that there is an urgent necessity of educational reform and training to rectify this problem.

Interventional radiology in low- and middle-income countries

With advancements in imaging techniques, interventional radiology (IR) has found an increased utility in multiple diseases such as ischemic stroke, tissue biopsies, oncology, trauma, etc. The benefit has been twofold in being minimally invasive and improved outcomes. IR in low- and middle-income countries (LMICs) is still in its nascent phase. The many hurdles include poorly structured post-graduate training, cost of procedures, and lack of awareness among referring physicians. There is a significant need to increase the trained specialists’ awareness among the medical community and rationalize the cost of procedures in LMICs with careful consideration, planning, and international economic and technical assistance.

Identification and Evaluation of Methodologies to Assess the Quality of Mobile Health Apps in High-, Low-, and Middle-Income Countries: Rapid Review

Background:
In recent years, there has been rapid growth in the availability and use of mobile health (mHealth) apps around the world. A consensus regarding an accepted standard to assess the quality of such apps has yet to be reached. A factor that exacerbates the challenge of mHealth app quality assessment is variations in the interpretation of quality and its subdimensions. Consequently, it has become increasingly difficult for health care professionals worldwide to distinguish apps of high quality from those of lower quality. This exposes both patients and health care professionals to unnecessary risks. Despite progress, limited understanding of the contributions of researchers in low- and middle-income countries (LMICs) exists on this topic. Furthermore, the applicability of quality assessment methodologies in LMIC settings remains relatively unexplored.

Objective:
This rapid review aims to identify current methodologies in the literature to assess the quality of mHealth apps, understand what aspects of quality these methodologies address, determine what input has been made by authors from LMICs, and examine the applicability of such methodologies in LMICs.

Methods:
This review was registered with PROSPERO (International Prospective Register of Systematic Reviews). A search of PubMed, EMBASE, Web of Science, and Scopus was performed for papers related to mHealth app quality assessment methodologies, which were published in English between 2005 and 2020. By taking a rapid review approach, a thematic and descriptive analysis of the papers was performed.

Results:
Electronic database searches identified 841 papers. After the screening process, 52 papers remained for inclusion. Of the 52 papers, 5 (10%) proposed novel methodologies that could be used to evaluate mHealth apps of diverse medical areas of interest, 8 (15%) proposed methodologies that could be used to assess apps concerned with a specific medical focus, and 39 (75%) used methodologies developed by other published authors to evaluate the quality of various groups of mHealth apps. The authors in 6% (3/52) of papers were solely affiliated to institutes in LMICs. A further 15% (8/52) of papers had at least one coauthor affiliated to an institute in an LMIC.

Conclusions:
Quality assessment of mHealth apps is complex in nature and at times subjective. Despite growing research on this topic, to date, an all-encompassing appropriate means for evaluating the quality of mHealth apps does not exist. There has been engagement with authors affiliated to institutes across LMICs; however, limited consideration of current generic methodologies for application in LMIC settings has been identified.

Application of the research electronic data capture (REDCap) system in a low- and middle income country– experiences, lessons, and challenges

The challenges of reliably collecting, storing, organizing, and analyzing research data are critical in low- and middle-income countries (LMICs), particularly in Sub-Saharan Africa where several healthcare and biomedical research organizations have limited data infrastructure. The Research Electronic Data Capture (REDCap) System has been widely used by many institutions and hospitals in the USA for data collection, entry, and management and could help solve this problem. This study reports on the experiences, challenges, and lessons learned from establishing and applying REDCap for a large US-Nigeria research partnership that includes two sites in Nigeria, (the College of Medicine of the University of Lagos (CMUL) and Jos University Teaching Hospital (JUTH)) and Northwestern University (NU) in Chicago, Illinois in the United States. The largest challenges to this implementation were significant technical obstacles: the lack of REDCap-trained personnel, transient electrical power supply, and slow/ intermittent internet connectivity. However, asynchronous communication and on-site hands-on collaboration between the Nigerian sites and NU led to the successful installation and configuration of REDCap to meet the needs of the Nigerian sites. An example of one lesson learned is the use of Virtual Private Network (VPN) as a solution to poor internet connectivity at one of the sites, and its adoption is underway at the other. Virtual Private Servers (VPS) or shared online hosting were also evaluated and offer alternative solutions. Installing and using REDCap in LMIC institutions for research data management is feasible; however, planning for trained personnel and addressing electrical and internet infrastructural requirements are essential to optimize its use. Building this fundamental research capacity within LMICs across Africa could substantially enhance the potential for more cross-institutional and cross-country collaboration in future research endeavors.

Global Surgery Education and Training Programmes—a Scoping Review and Taxonomy

Global surgery is an emerging field of study and practice, aiming to respond to the worldwide unmet need for surgical care. As a relatively new concept, it is not clear that there is a common understanding of what constitutes “global surgery education and training”. This study examines the forms that global surgery education and training programmes and interventions take in practice, and proposes a classification scheme for such activities. A scoping review of published journal articles and internet websites was performed according to the PRISMA Extension for Scoping Review guidelines. PubMed MEDLINE, EMBASE and Google were searched for sources that described global surgery education and training programme. Only sources that explicitly referenced a named education programme, were surgical in nature, were international in nature, were self-described as “global surgery” and presented new information were included. Three hundred twenty-seven records were identified and 67 were ultimately included in the review. “Global surgery education and training” interventions described in the literature most commonly involved both a High-Income Country (HIC) institution and a Low- and Middle-Income Country (LMIC) institution. The literature suggests that significant current effort is directed towards academic global surgery programmes in HIC institutions and HIC surgical trainee placements in LMICs. Four categories and ten subcategories of global surgery education and training were identified. This paper provides a framework from which to study global surgery education and training. A clearer understanding of the forms that such interventions take may allow for more strategic decision making by actors in this field