Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

Background
Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods
From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results
Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion
Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.

Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting

Introduction
Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients.

Methods
A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression.

Results
31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%).

Conclusion
Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum

Introduction:
Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment.

Methods:
Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic analysis with an iterative coding was used to analyze the data. The primary objective was to identify provider-perceived themes related to TBI care in Mumbai.

Results:
A total of 50 participants were interviewed, including 17 paramedics, 15 anesthesiologists, 9 general surgeons, and 9 neurosurgeons who were involved in caring for TBI patients. The majority of physicians interviewed discussed their experiences in public sector hospitals (82%), while 12% discussed private sector hospitals and 6% discussed both. Four major themes emerged: Workforce, equipment, financing care, and the family and public role. These themes were often discussed in the context of their effects on increasing or decreasing complications and delays. Participants developed adaptations when managing shortcomings in these thematic areas. These adaptations included teamwork during workforce shortages and resource allocation when equipment was limited among others.

Conclusions:
Workforce, equipment, financing care, and the family and public role were identified as major themes in the care for TBI in Mumbai. These thematic elements provide a framework to evaluate and improve care along the care spectrum for TBI. Similar frameworks should be adapted to local contexts in urbanizing cities in LMICs.

Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial

Background: While cesarean sections (CSs) are a life-saving intervention, an increasing number are performed without medical reasons in low- and middle-income countries (LMICs). Unnecessary CS diverts scarce resources and thereby reduces access to healthcare for women in need. Argentina, Burkina Faso, Thailand, and Vietnam are committed to reducing unnecessary CS, but many individual and organizational factors in healthcare facilities obstruct this aim. Nonclinical interventions can overcome these barriers by helping providers improve their practices and supporting women’s decision-making regarding childbirth. Existing evidence has shown only a modest effect of single interventions on reducing CS rates, arguably because of the failure to design multifaceted interventions effectively tailored to the context. The aim of this study is to design, adapt, and test a multifaceted intervention for the appropriate use of CS in Argentina, Burkina Faso, Thailand, and Vietnam.

Methods: We designed an intervention (QUALIty DECision-making-QUALI-DEC) with four components: (1) opinion leaders at heathcare facilities to improve adherence to best practices among clinicians, (2) CS audits and feedback to help providers identify potentially avoidable CS, (3) a decision analysis tool to help women make an informed decision on the mode of birth, and (4) companionship to support women during labor. QUALI-DEC will be implemented and evaluated in 32 hospitals (8 sites per country) using a pragmatic hybrid effectiveness-implementation design to test our implementation strategy, and information regarding its impact on relevant maternal and perinatal outcomes will be gathered. The implementation strategy will involve the participation of women, healthcare professionals, and organizations and account for the local environment, needs, resources, and social factors in each country.

Discussion: There is urgent need for interventions and implementation strategies to optimize the use of CS while improving health outcomes and satisfaction in LMICs. This can only be achieved by engaging all stakeholders involved in the decision-making process surrounding birth and addressing their needs and concerns. The study will generate robust evidence about the effectiveness and the impact of this multifaceted intervention. It will also assess the acceptability and scalability of the intervention and the capacity for empowerment among women and providers alike.

Management of neuroblastoma in limited-resource settings

BACKGROUND
Neuroblastoma (NB) is a heterogeneous disease with variable outcomes among countries. Little is known about NB in low- and middle-income countries (LMICs).

AIM
The aim of this review was to evaluate regional management protocols and challenges in treating NB in paediatric oncology units in LMICs compared to high-income countries (HICs).

METHODS
PubMed, Global Health, Embase, SciELO, African Index Medicus and Google Scholar were searched for publications with keywords pertaining to NB, LMICs and outcomes. Only English language manuscripts and abstracts were included. A descriptive review was done, and tables illustrating the findings were constructed.

RESULTS
Limited information beyond single-institution experiences regarding NB outcomes in LMICs was available. The disease characteristics varied among countries for the following variables: sex, age at presentation, MYCN amplification, stage and outcome. LMICs were found to be burdened with a higher percentage of stage 4 and high-risk NB compared to HICs. Implementation of evidence-based treatment protocols was still a barrier to care. Many socioeconomic variables also influenced the diagnosis, management and follow-up of patients with NB.

CONCLUSION
Patients presented at a later age with more advanced disease in LMICs. Management was limited by the lack of resources and genetic studies for improved NB classification. Further research is needed to develop modified diagnostic and treatment protocols for LMICs in the face of limited resources.

Pediatric Solid Tumor Care and Multidisciplinary Tumor Boards in Low- and Middle-Income Countries in Southeast Asia

PURPOSE
Pediatric solid tumors require coordinated multidisciplinary specialist care. However, expertise and resources to conduct multidisciplinary tumor boards (MDTBs) are lacking in low- and middle-income countries (LMICs). We aimed to profile the landscape of pediatric solid tumor care and practices and perceptions on MDTBs among pediatric solid tumor units (PSTUs) in Southeast Asian LMICs.

METHODS
Using online surveys, availability of specialty manpower and MDTBs among PSTUs was first determined. From the subset of PSTUs with MDTBs, one pediatric surgeon and one pediatric oncologist from each center were queried using 5-point Likert scale questions adapted from published questionnaires.

RESULTS
In 37 (80.4%) of 46 identified PSTUs, availability of pediatric-trained specialists was as follows: oncologists, 94.6%; surgeons, 91.9%; radiologists, 54.1%; pathologists, 40.5%; radiation oncologists, 29.7%; nuclear medicine physicians, 13.5%; and nurses, 81.1%. Availability of pediatric-trained surgeons, radiologists, and pathologists was significantly associated with the existence of MDTBs (P = .037, .005, and .022, respectively). Among 43 (89.6%) of 48 respondents from 24 PSTUs with MDTBs, 90.5% of oncologists reported > 50% oncology-dedicated workload versus 22.7% of surgeons. Views on benefits and barriers did not significantly differ between oncologists and surgeons. The majority agreed that MDTBs helped to improve accuracy of treatment recommendations and team competence. Complex cases, insufficient radiology and pathology preparation, and need for supplementary investigations were the top barriers.

CONCLUSION
This first known profile of pediatric solid tumor care in Southeast Asia found that availability of pediatric-trained subspecialists was a significant prerequisite for pediatric MDTBs in this region. Most PSTUs lacked pediatric-trained pathologists and radiologists. Correspondingly, gaps in radiographic and pathologic diagnoses were the most common limitations for MDTBs. Greater emphasis on holistic multidisciplinary subspecialty development is needed to advance pediatric solid tumor care in Southeast Asia.

Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery

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.

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

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.

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

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.

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

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.