Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians

Background
In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers’ perspectives.

Methods
We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.

Results
We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.

Conclusion
Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.

Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey

Study Design: Cross-sectional, international survey.
Objectives: This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis
during spine surgery along with its risks and benefits.
Methods: A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was
distributed to AO Spine’s spine surgeon members (N ¼ 3805). Data included surgeon demographic information, type and region
of practice, anticoagulation principles, different patient scenarios, and comorbidities.
Results: A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to
44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most
surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a
procedure (P ¼ .036) and patient body mass index (P ¼ .008) were perceived differently when deciding to begin anticoagulation,
while the importance of medical clearance (P < .001) and reference to literature (P ¼ .035) differed during cessation. For specific
techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on
postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant
initiation on postoperative 0 to 1 days or days 5-6
Conclusion: This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it
identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no
widely accepted, definitive literature of evidence or guidelines.

Barriers to Neurosurgical Training in Sub-Saharan Africa: The Need for a Phased Approach to Global Surgery Efforts to Improve Neurosurgical Care

BACKGROUND: Neurosurgery in low-income countries is faced with multiple challenges. Although the most common challenges include infrastructure and physical resource deficits, an underemphasized barrier relates to the methods and components of surgical training. The role of important aspects, including didactic surgical training, surgical decision-making, workshops, conferences, and assessment methods, has not been duly studied. Knowledge of these issues is a crucial step to move closer to strengthening surgical capacity in low-income countries.
METHODS: We designed an online survey to assess self-perceived and objectively measured barriers to neurosurgical training in various Sub-Saharan African countries. Key outcomes included perception toward adequacy of neurosurgery training and barriers to neurosurgical training at each individual site.
RESULTS: Only 37% of responders felt that their training program adequately prepared them for handling incoming neurosurgical cases. Top perceived limitations of neurosurgery training included lack of physical resources (25% of all responses), lack of practical workshops (22%), lack of program structure (18%), and lack of topic-specific lectures (10%).
CONCLUSIONS: Our results show that most responders believe their training program is inadequate and are interested in improving it through international collaborations. This implies that activities directed at strengthening surgical capacity must address this important necessity. One important strategy is the use of online educational tools. In consideration of the observed limitations in care, resources, and training, we recommend a phased approach to neurosurgical growth in low-income settings.

Patient Barriers to Accessing Surgical Cleft Care in Vietnam: A Multi-site, Cross-Sectional Outcomes Study.

BACKGROUND:
Most people who lack adequate access to surgical care reside in low- and lower-middle-income countries. Few studies have analyzed the barriers that determine the ability to access surgical treatment. We seek to determine which barriers prevent access to cleft care in a resource-limited country to potentially enable barrier mitigation and improve surgical program design.

METHODS:
A cross-sectional, multi-site study of families accessing care for cleft lip and palate deformities was performed in Vietnam. A survey instrument containing validated demographic, healthcare service accessibility, and medical/surgical components was administered. The main patient outcome of interest was receipt of initial surgical treatment prior to 18 months of age.

RESULTS:
Among 453 subjects enrolled in the study, 216 (48%) accessed surgical care prior to 18 months of age. In adjusted regression models, education status of the patient’s father (OR 1.64; 95% CI 1.1-2.5) and male sex (OR 1.61; 95% CI 1.1-2.4) were both associated with timely access to care. Distance and associated cost of travel, to either the nearest district hospital or to the cleft surgical mission site, were not associated with timing of access. In a sensitivity analysis considering care received prior to 24 months of age, cost to attend the surgical mission was additionally associated with timely access to care.

CONCLUSIONS:
Half of the Vietnamese children in our cohort were not able to access timely surgical cleft care. Barriers to accessing care appear to be socioeconomic as much as geographical or financial. This has implications for policies aimed at reaching vulnerable patients earlier.