High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone

Objective:
Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone.

Methods:
We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software.

Results:
Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%).

Conclusions:
We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

Global economic burden of unmet surgical need for appendicitis

Background
There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis.

Methods
Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism.

Results
Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality.

Conclusion
For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially.

Global Neurosurgery in the Context of Global Public Health Practice–A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well.

For example, vitamin B12 and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs.

Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeons

Improving District Hospital Surgical Capacity in Resource Limited Settings: Challenges and Lessons From South Africa

Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries (LMICs) has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings.
Surgical team mentoring programs require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for a

Innovations in surgery between the past and future: A narrative review of targeted literature

Innovation is the introduction of a new method or technology designed to change the way things are done. History is full of remarkable innovations in surgery over the years as surgeons have always been innovating and pioneering latest techniques and equipment that can benefit the mankind. Though persistent, progress has been far from uniform. Despite all the bells and whistles that these innovations bring to the table, the little acknowledged fact is that they are only accessible to a very small proportion of the global population. Five billion people on this planet do not even have access to an operating room when needed. It has been reported that conditions requiring surgery are responsible for one-third of all the deaths in the world. The current narrative review was planned to focus on the importance of innovations in surgery, to highlight the problems that were faced by resource-restricted countries in the past, and the necessity of innovative solutions to improve global surgical care in the future.

Analysing the trends in breast surgery practice during COVID-19 pandemic: A comparative study with the Pre-COVID era

The emergence of coronavirus disease 2019 (COVID-19) pandemic has crippled the healthcare systems all over the world. Cancer treatment is indispensable and disruption in its provision can lead to unanticipated consequences. No local data exists that has quantified the impact of COVID-19 pandemic on breast cancer surgery in a lower middle-income country (LMIC), therefore, the present retrospective comparative cohort study is directed to determine the trends in breast surgery operative volumes and its outcomes at our institution in Pakistan.

Materials and methods
Data was collected retrospectively from Pre-COVID-19 and COVID-19 era to determine impact of the current pandemic on breast cancer management practices and outcomes.

Results
Cohort results showed a decline in the number of surgeries during COVID-19 era. A total 149 cases were operated during study period vs. 231 during same Pre-COVID-19 i.e. a 35.5% drop in cancer surgeries. In early COVID-19 time frame, only 4 patients had breast reconstruction, 12 out of 149 (8.05%) surgical candidates were identified having positive COVID-19 status preoperatively and one ASA class 3 patient caught COVID-19 post-surgery and succumbed to virus.

Conclusion
Pandemic has a negative effect on cancer management in a LMIC with compromised access and care of cancer patients.

PakSurg: The first trainee-lead model for multicenter surgical research collaboration in Pakistan

We describe creation and piloting of the PakSurg Collaborative, devised via integration of existing trainee-led collaborative models in the United Kingdom with the resource-limited surgical care in Pakistan. This is the first trainee-lead surgical research collaborative in Pakistan, established by the student-lead Surgery Interest Group from the Aga Khan University. The project involved creation of a model that included a steering committee comprising of five teams which worked in conjunction with collaborators from multiple hospitals. To facilitate this collaboration, a comprehensive and cost-efficient study management pathway was developed. The PakSurg Collaborative has the potential to deliver methodologically robust, high-quality, multicenter surgical evidence from Pakistan. This nationally representative data could inform evidence-based surgical guidelines, potentially translating into improved outcomes for patients undergoing surgery.

Feasibility of delivering foot and ankle surgical courses in a partnership in Eastern, Central and Sothern Africa

Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the “Principles of Foot and Ankle Surgery” course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as “Poor”, “Below average”, “Average”, “Good” and “Excellent”, which was converted into a value from 1–5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann–Whitney) test, and significance was considered to be p < 0.05.

Inspirational Women in Surgery: Dr. Olive Kobusingye, Uganda

Dr. Olive Kobusingye has spent her career taking on an enormous challenge—improving trauma care in Uganda, in Africa, and worldwide. She was born in a village in southwestern Uganda, 5th in a family of six children. Her mother was a teacher and her father was a policeman and later a trader in agricultural produce. Both of her parents died young—her father when she was five and her mother when she was eleven. She went to all-girls missionary boarding schools until university. Her first ambition was to be an engineer, but she was talked out of it by her elder brother who was then at medical school. He told her that at Makerere University women did not do well in engineering no matter how bright they were. Medicine was her second choice.

Once at Makerere, she at first thought of going into forensic pathology and then psychiatry, but neither really caught her attention. Surgery was different. She saw patients brought in half dead and revived within a few hours of intervention. Her five years at medical school coincided with the five years that the National Resistance Army fought a civil war that left more than half a million Ugandans dead. She saw many victims of the war during her training. She did a rotating internship at Machakos General Hospital, in Kenya, to experience medicine in a more stable environment. It was here that she decided to pursue a career in surgery. Dr. Mohamad Alkama was head of surgery, and it was a joy to scrub for him. His operating lists included a great variety of surgeries, ranging from neurosurgery, orthopedics, general surgery and pediatric surgery. He did all of them with a positive attitude, always giving interns opportunities for hands-on experience during the surgery.

Two years later she returned to Uganda to begin her surgical residency and found that medical services were still quite poor. Shortages were a constant frustration—shortage of almost everything—sutures, equipment, anaesthesia, medicines, lab reagents. To compound the problem, AIDS was ravaging the country, putting medical workers at great risk. But, she felt herself very fortunate to have excellent surgeons as her teachers, especially Prof. JC Ssali who was her immediate supervisor, and who turned out to be a quieter, older version of Dr. Alkama.

Later when she decided to focus on accident & emergency surgery, the shortages did not let up, yet her patients could not wait for relatives to go and sell household property to buy medical supplies. The cost of mismanaged medical services in terms of lives needlessly lost was always “in her face”—especially the year she spent as the Acting Head of the Accident & Emergency at Mulago Hospital, the main hospital in the country. Frustrated at the many needless injuries, especially from road traffic crashes, she decided to take on trauma care and injury prevention as the focus of her career.

Over the ensuing two decades, she has been a major force in promoting both trauma care and injury prevention in low- and middle-income countries (LMICs) globally. She founded the Injury Prevention Center at Makere University, one of the first academic injury prevention centers in Africa. Her research addressed straightforward ways to improve care for the injured in LMICs, something that she realized was possible, despite the extreme resource limitations. A major scientific contribution was her development of the Kampala Trauma Score (KTS), a simple way to risk-adjust injured patients, especially in locations where it would be difficult and time consuming to use the more complex scales used in high-income countries. The KTS is now used around the world. She also co-developed a training course for teams working in emergency units—the Trauma Team Training course. She has looked for ways to improve trauma care broadly in many countries, spending 5 years as the WHO Regional Adviser on Injury for Africa, based in Brazzaville, Congo, providing input on trauma care to 46 African countries.

She has always had an ability to see beyond the immediate problems, to the bigger issues that hamper care in places like Uganda. She states: “In trauma, patients are still getting debilitating osteomyelitis because there is not enough saline to do a decent debridement. Patients are dying for lack of a chest tube. These problems are not for ‘the surgical community’ to resolve. They are political problems. Perhaps the surgical community needs to begin addressing upstream factors which make our practice of surgery an impossible task.” This has led her to write two books addressing such bigger factors, in medical care overall and in politics [1, 2].

Despite the numerous frustrations in her work, she maintains a hopeful outlook. “I did not foresee it back then, but the thing I am most proud of now is having spent time with students. Having taken the time to show younger doctors how to do procedures that truly mattered to patients’ recovery. Even with severe shortages, there is always something we can offer patients. Good listening and a thorough exam. Gadgets are great, and if one has them, they should definitely use them to the max, but nothing seems to be able to replace good clinical acumen yet.”

An OxPLORE Initiative Evaluating Children’s Surgery Resources Worldwide: A Cross-sectional Implementation of the OReCS Document

Background
The Global Initiative for Children’s Surgery (GICS) group produced the Optimal Resources for Children’s Surgery (OReCS) document in 2019, listing standards of children’s surgical care by level of healthcare facilities within low resource settings. We have previously created and piloted an audit tool based on the OReCS criteria in a high-income setting. In this study, we aimed to validate its use in identifying gaps in children’s surgery provision worldwide.

Methods
Our OReCS audit tool was implemented in 10 hospitals providing children’s surgery across eight countries. Collaborators were recruited via the Oxford Paediatrics Linking Our Research with Electives (OxPLORE) international network of medical students and trainees. The audit tool measured a hospital’s current capacity for children’s surgery. Data were analysed firstly to express the percentage of ‘essential’ criteria met for each specialty. Secondly, the ‘OxPLORE method’ was used to allocate each hospital specialty a level based on procedures performed and resources available. A A User Evaluation Tool (UET) was developed to obtain feedback on the ease of use of the tool.

Results
The percentage of essential criteria met within each category varied widely between hospitals. The level given to hospitals for subspecialties based on OReCS criteria often did not reflect their self-defined level. The UET indicated the audit tool was practicable across multiple settings.