The role of community health workers in the surgical cascade: a scoping review

Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade.

We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data.

The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event.

While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.

Surgical Management and Outcomes of Wilms Tumor in Rwanda: A Retrospective Study of Patients Operated on at the University Teaching Hospital of Kigali-Rwanda

BACKGROUND: Wilms tumor is the most common renal tumor in children and accounts for 6-8% of all childhood malignancies and has a variable survival rate worldwide. The aim of this study was to describe the surgical management and outcomes of care for Wilms tumor patients operated at the University Teaching Hospital of Kigali (CHUK).
METHODS: This is a retrospective chart review conducted at CHUK in Rwanda. It includes all children who had a confirmed Wilms tumor diagnosis operated from July 2012 to June 2016. Patient’s demographics, staging, surgical management, and outcomes were analyzed.
RESULTS: A total of 58 patients diagnosed with Wilms tumor were identified. 52.6% were female. The median age was four years, interquartile range (IQR): 1-10 years. The majority of the children were stage II (39.7%) and the minority being stage V (5.2%). Treatment offered was in accordance with the Societe Internationale d’ Oncologie Pediatrique (SIOP) protocol; 91.2% of patients received four weeks of preoperative chemotherapy and a median of 15 weeks postoperative chemotherapy (IQR: 8,26). The resection rate was 100% for those with unilateral tumors. The spillage rate was 15.8%. At the time of the study, the mortality rate was 19.3%, recurrence was 7%, and 12.3% were lost to follow-up.
CONCLUSION: The introduction of a single national protocol for treating Wilms tumor in Rwanda with a dedicated management team, including the surgical and pediatric oncology services, has led to early outcomes approaching the ones in high-income countries, but efforts also need to include earlier detection of this tumor.

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

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

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

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

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

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

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.
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).
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.

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

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.

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).

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.