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Hewitt-Smith A, Bulamba F, Patel A, Nanimambi J, Adong LR, Emacu B, Kabaleta M, Khanyalano J, Maiga AH, Mugume C, Nakibuule J, Nandyose L, Sejja M, Weere W, Stephens T, Pearse RM. Family supplemented patient monitoring after surgery (SMARTER): a pilot stepped-wedge cluster-randomised trial. Br J Anaesth 2024; 133:846-852. [PMID: 39069451 DOI: 10.1016/j.bja.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/07/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Mortality after surgery in Africa is twice that in high-income countries. Most deaths occur on wards after patients develop postoperative complications. Family members might contribute meaningfully and safely to early recognition of deteriorating patients. METHODS This was a stepped-wedge cluster-randomised trial of an intervention training family members to support nursing staff to take and record patient vital signs every 4 h after surgery. Adult inpatients across four surgical wards (clusters) in a Ugandan hospital were included. Clusters crossed once from routine care to the SMARTER intervention at monthly intervals. The primary outcome was frequency of vital sign measurements from arrival on the postoperative ward to the end of the third postoperative day (3 days). RESULTS We enrolled 1395 patients between April and October 2021. Mean age was 28.2 (range 5-89) yr; 85.7% were female. The most common surgical procedure was Caesarean delivery (74.8%). Median (interquartile range) number of sets of vital signs increased from 0 (0-1) in control wards to 3 (1-8) in intervention wards (incident rate ratio 12.4, 95% confidence interval [CI] 8.8-17.5, P<0.001). Mortality was 6/718 (0.84%) patients in the usual care group vs 12/677 (1.77%) in the intervention group (odds ratio 1.32, 95% CI 0.1-14.7, P=0.821). There was no difference in length of hospital stay between groups (usual care: 2 [2-3] days vs intervention: 2 [2-4] days; hazard ratio 1.11, 95% CI 0.84-1.47, P=0.44). CONCLUSIONS Family member supplemented vital signs monitoring substantially increased the frequency of vital signs after surgery. Care interventions involving family members have the potential to positively impact patient care. CLINICAL TRIAL REGISTRATION NCT04341558.
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Affiliation(s)
- Adam Hewitt-Smith
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK; Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Busitema University, Mbale, Uganda; Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda.
| | - Fred Bulamba
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK; Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Busitema University, Mbale, Uganda; Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Akshaykumar Patel
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Juliana Nanimambi
- Comprehensive Rehabilitation Services in Uganda (CoRSU) Hospital, Kisubi, Uganda
| | - Lucy R Adong
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Bernard Emacu
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Mary Kabaleta
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | | | - Ayub H Maiga
- Nexus Centre for Research and Innovations (NCRI), Wakiso, Uganda
| | - Charles Mugume
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | | | - Loretta Nandyose
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Martin Sejja
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Winfred Weere
- Elgon Centre for Health Research and Innovation (ELCHRI), Mbale, Uganda
| | - Timothy Stephens
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rupert M Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
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Pérez Rivera CJ, Lozano-Suárez N, Velandia-Sánchez A, Vargas-Cuellar MP, Rojas-Serrano LF, Polanía-Sandoval CA, Lara-Espinosa D, García-Zambrano L, Bohórquez-Tarazona MP, Agudelo-Mendoza SV, Cabrera-Rivera PA, Briceno-Ayala L. Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery - a prospective cohort study. LANCET REGIONAL HEALTH. AMERICAS 2024; 38:100862. [PMID: 39253707 PMCID: PMC11382124 DOI: 10.1016/j.lana.2024.100862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 07/07/2024] [Accepted: 07/31/2024] [Indexed: 09/11/2024]
Abstract
Background Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. Methods A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. Findings 3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively. Interpretation The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. Funding This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.
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Affiliation(s)
| | - Nicolás Lozano-Suárez
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Alejandro Velandia-Sánchez
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | | | | | - Camilo A Polanía-Sandoval
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Daniela Lara-Espinosa
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Laura García-Zambrano
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
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Pittalis C, Sackey C, Okeny P, Nandi B, Gajewski J. Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature. BMJ Qual Saf 2024; 33:653-662. [PMID: 38160058 DOI: 10.1136/bmjqs-2023-016823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices. METHODS A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence. RESULTS A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process. CONCLUSION There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.
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Affiliation(s)
- Chiara Pittalis
- Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Cherie Sackey
- Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Paul Okeny
- Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bip Nandi
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- Michael E Debakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jakub Gajewski
- Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Aboderin AO, Amfoabegyi S, Awopeju AT, Bahrami-Hessari M, Garchie EIA, Gill M, Karikari A, Kirby A, Makanjuola O, Mutiu B, Offiong AB, Oshun PO, Osumanu HA, Owusu-Ofori A, Varghese SR, Adam-Zakariah LI, Adebanjo AT, Aguirre CC, Akoto E, Aminu A, Armah R, Aruldas ND, Choudhrie AV, Coompson CL, Ekwunife OH, Fourtounas M, Lawani S, Mathew AJ, Patel A, Ademuyiwa AO, Hardy P, Runigamugabo E, Sodonougbo P, Behanzin H, Kangni S, Agboton G, Adagrah LA, Adjei-Acquah E, Acquah AO, Ankomah J, Armah R, Acquah R, Addo KG, Acheampong DO, Adu-Aryee NA, Abubakari F, Titigah A, Owusu F, Adu-Brobbey R, Adobea V, Abantanga FA, Gautham A, Bhatti D, Jesudason EDM, Aggarwal M, Alexander P, Dasari A, Alpheus R, Kumar H, Raul S, Bueno WÁ, Ortiz RC, Gomez IB, Cerdan CC, Gallo MB, Gamez RR, Sánchez ID, Abdullahi L, Adesanya O, Abdulsalam M, Adeleye V, Egwuonwu O, Adeleke A, Adebayo F, Chiejina G, Abayomi O, Abdur-Rahman L, Ede J, Ezinne U, Kanyarukiko S, Dusabe M, Hirwa AD, Bucyibaruta G, Adams MA, Birtles C, Ally Z, Adewunmi AS, Cook J, Brown J, Adisa AO, Ismail L, Bhangu A, Omar O, Simoes JFF, Li E, Chaudhry D, Saeed S, Spurring EM, Verjee A, Assouto P, Seto DM, Kpangon C, Ahossi R, Alhassan BBA, Agyekum V, Adam-Zakariah LI, Assah-Adjei F, Asare C, Amoako J, Akosa EA, Acquaye J, Adjei F, Ballu C, Coompson CL, Bennin A, Abdulai DR, Hepzibah A, Bhatti W, Paul PK, Dhamija P, Thomas J, Jacob P, Choudhrie A, Peters N, Sharma R, Camacho FB, Gonzalez GH, Aguirre CC, Solano DD, Flores AC, Menindez RL, Vazquez DG, Ado K, Awonuga D, Adeniran A, Ademuyiwa A, Ekwunife O, Adenikinju W, Aisuodionoe-Shadrach O, Edet E, Abdus-Salam R, Adeleke N, Ekenze S, Francis M, Mukaneza F, Izabiriza E, Kabanda E, Bunogerane GJ, Crawford R, Ivy M, Jayne D, Cousens S, Chakrabortee S, Ghosh D, Gyamfi FE, Brant F, Fiogbe M, Tandje Y, Akpla M, Ngabo RB, Amoako-Boateng MP, Agyemang E, Asabre E, Boakye AA, Gakpetor DA, Appiah AD, Boakye P, Adinku M, Akoto E, Barimah CG, Labaran AH, Dankwah F, Acquah DK, Mary G, Bir K, Madankumar L, Gupta H, Zechariah P, Kurien E, Vakil R, Hernández AB, Krauss RH, Avendaño AC, Garcia RT, Ojeda AG, Peón AN, Lara MM, Aliyu M, Fasiku O, Ajai O, Adeniyi O, Modekwe V, Adeniyi O, Akaba G, Inyang A, Adebayo S, Adesola M, Enemuo V, Ikechukwu I, Mukantibaziyaremye D, Maniraguha HL, Mbonimpaye S, Habumuremyi S, Ede CJ, Mbavhalelo C, Laurberg S, Smart N, de la Medina AR, Brocklehurst P, Koco H, Chobli HH, Bisimwa N, Appiah AB, Akesseh RA, Boateng RA, Fosu G, Gawu VS, Aseti M, Coompson CL, Agbedinu K, Ametefe E, Boateng GC, Owusu JA, Doe S, Ayingayure E, Singh D, Daniel S, Mittal R, Kanna V, Mathew A, Arellano AB, Miguelena LH, Sansores LD, Velasco MJ, Muñoz MP, Perez-Maldonado LM, Anyanwu LJ, Ogo C, Akande O, Akinajo O, Okoro C, Adepiti A, Ameh L, Isa M, Ajao A, Afolabi R, Eze M, Nnyonno O, Munyaneza A, Mpirimbanyi C, Mukakomite C, Haragirimana JDD, Fourtounas M, Moore R, Chakrabortee S, Metchinhoungbe S, Kovohouande B, Kandokponou CMB, Asante-Asamani A, Amponsah-Manu F, Koomson B, Serbeh G, Obbeng A, Banka C, Gyamfi B, Agbeko AE, Amoako JK, Luri PT, Kantanka RS, Osman I, Dhar T, Nagomy I, Kumar A, Prakash D, Torres EC, Romero MH, Mejia HO, de la Fuente ANS, Magashi M, Atobatele K, Akinboyewa D, Uche C, Aderounmu A, Mbajiekwe N, Iseh F, Amusat O, Agodirin S, Ezomike U, Okoro P, Ndegamiye G, Mutuyimana J, Muroruhirwe P, Imanishimwe A, Hyman G, Hardy P, Ntirenganya F, Sogbo H, Dokponou M, Boakye B, Ofosu-Akromah R, Kusiwaa A, Gyan KY, Ofosuhene D, Dadzie S, Kontor BE, Amankwa EG, Attepor GS, Kobby E, Kunfah S, Dhiman J, Selvakumar R, Singh G, Susan A, Orozco CF, del Campo LUG, de la Medina ARD, Muhammad A, Eke G, Alasi I, Ugwuanyi K, Adesunkanmi A, Ogbo F, Marwa A, Ayandipo O, Aremu I, Izuka E, Patrick I, Tubasiime R, Mwenedata O, Ingabire JCA, Khan Z, Harrison E, Tabiri S, Glasbey J, Dossou FM, Debrah SA, Enti D, Twerefour EY, Nyarko IO, Osei-Poku D, Essien D, Kyeremeh C, Amoah M, Brown GD, Larnyor KKKH, Limann G, Ghosh D, Shankar B, Varghese R, de Rojas EGG, Muhammad S, Faboya O, Alakaloko F, Ugwunne C, Adisa A, Olori S, Ogbeche S, Egbuchulem K, Bello J, Mbadiwe O, Raphael J, Rwagahirima E, Mukanyange V, Kwati M, Dzemta C, Ganiyu RA, Robertson Z, Puozaa D, Gyamfi FE, Manu R, Amoah G, Fenu B, Osei E, Mohammed SA, Goyal S, Sivakumar M, Muideen B, Imam Z, Atoyebi O, Ajekwu S, Osagie O, Olory E, Ekwuazi H, Lawal S, Mbah N, Vaduneme O, Uwizeyimana F, Munyaneza E, Mathe MN, Haque PD, Gaou A, Koggoh P, Tackie E, Hussey R, Mensah E, Appiah J, Kumassah PK, Owusu PY, Mohammed S, Goyal A, Sridhar R, Ramírez BG, Takai I, Momson E, Balogun O, Ajenjfuja O, Sadiq A, Udie G, Elemile P, Lawal A, Victor A, Zirikana J, Mutabazi E, Moore R, Heritage E, Goudou R, Kpankpari R, Temitope AE, Kwarteng J, Solae FI, Arthur J, Olayiwola DO, Sie-Broni CA, Musah Y, Goyal S, Thomas C, Valadez MHV, Ukata O, Nwaenyi F, Belie O, Akindojutimi J, Sani S, Udosen J, Lawal T, Raji H, Ncogoza I, Nhlabathi NA, Hedefoun E, Opandoh INM, Sowah NA, Toffah GK, Ayim A, Wordui T, Zume M, Ofori B, Hans M, Titus D, Acevedo DL, Ogunyemi A, Bode C, Akinkuolie A, Tabuanu N, Usang U, Lawal O, Sayomi O, Ntirenganya F, Nxumalo HS, Kroese K, Houtoukpe S, Manu MA, Yeboah G, Ayodeji EK, Agboadoh N, Owusu EA, Haque P, Galaviz RM, Oludara M, Ekwesianya A, Alatise O, Uanikhoba M, Olagunju S, Shittu A, Nyirahabimana J, Pattinson P, Lillywhite R, Lapitan C, Kamga F, Manu MPO, Yeboah C, Boakye-Yiadom J, Saba AH, Konda S, Flores OO, Omisanjo O, Elebute O, Allen O, Osuala P, Urimubabo C, Sentholang N, Kiki-Migan E, Mensah S, Boateng EA, Seidu AS, Luther A, Navarro JP, Oshodi O, Ezenwankwo F, Amosu L, Suleman B, Sethoana ME, Lissauer D, Lawani S, Morna MT, Dally C, Tabiri S, Mahajan A, Belmontes KP, Oshodi Y, Fatuga A, Archibong M, Takure A, Stassen ME, Magill L, Lawani I, Nkrumah J, Davor A, Yakubu M, Makkar S, Marbello FR, Oyewole Y, Ihediwa G, Arowolo O, Thornley L, Morton D, Loko R, Nortey M, Gyasi-Sarpong CK, Yenli EMTA, Mandrelle K, Ramírez-González L, Salami O, Jimoh A, Ayantona D, Wondoh P, Nepogodiev D, Mistry P, Moutaïrou A, Ofori EO, Hamidu NNN, Michael V, Aguirre LR, Williams O, Kuku J, Ayinde A, Monahan M, Ogouyemi P, Quartson EMQ, Haruna I, Mukherjee P, García RR, Ladipo-Ajayi O, Badejoko O, Soumanou F, Kwarley N, Rajappa R, Robles EV, Makanjuola A, Badmus T, Smith D, Tamadaho P, Lovi AK, Singh P, Mokwenyei O, Etonyeaku A, Zounon MA, Nimako B, Suroy A, Nwokocha S, Igbodike E, Nyadu BB, Thind R, Ogein O, Ijarotimi O, Opoku D, Thomas A, Ojewola R, Lawal A, Pinkney T, Osabutey A, Tuli A, Oladimeji A, Nana F, Roberts T, Sagoe R, Veetil S, Olajide T, Oduanafolabi T, Tuffour S, Oluseye O, Olasehinde O, Tufour Y, Seyi-Olajide J, Olayemi O, Winkles N, Yamoah FA, Soibi-Harry A, Omitinde S, Yefieye AC, Ugwu A, Oni O, Yorke J, Williams E, Onyeze C, Orji E, Rotimi A, Salako A, Solaja O, Sowemimo O, Talabi A, Tajudeen M, Wuraola F. Microbiology testing capacity and antimicrobial drug resistance in surgical-site infections: a post-hoc, prospective, secondary analysis of the FALCON randomised trial in seven low-income and middle-income countries. Lancet Glob Health 2024:S2214-109X(24)00330-9. [PMID: 39245054 DOI: 10.1016/s2214-109x(24)00330-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 07/21/2024] [Accepted: 07/25/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Surgical-site infection (SSI) is one of the most common health-care-associated infections, substantially contributing to antibiotic use. Targeted antibiotic prophylaxis to prevent SSIs and effective treatment are crucial to controlling antimicrobial resistance (AMR). This study aimed to describe the testing capacity and multidrug resistance (MDR) of SSI microorganisms in low-income and middle-income countries (LMICs). METHODS This analysis included patients undergoing abdominal surgery in seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa) as part of the FALCON randomised controlled trial. Wound swabs were collected from patients diagnosed with SSI, as per US Centers for Disease Control and Prevention (CDC) definition. Data on microorganism species and MDR, as per CDC and European Centre for Disease Prevention and Control definitions, were analysed alongside hospital-level data on local microbiological practices. An adjusted analysis was performed to identify perioperative factors associated with MDR. Testing capacity was assessed by the completion of swab testing in positively diagnosed SSIs. FINDINGS Between Dec 10, 2018, and Sept 7, 2020, 5788 patients were recruited to the FALCON trial. 1163 patients were diagnosed with an SSI, of whom 905 (77·8%) received prophylactic antibiotics before surgery. In patients with SSIs, 935 of 1163 (80·4%) did not have a wound swab; 195 were from hospitals not performing swabs (15 hospitals) and 740 were from hospitals with capacity but no swab performed (35 hospitals). Of 228 patients swabbed, 200 (88·5%) had microorganisms detected. Escherichia coli (89 of 200, 37·9%) was the most common microorganism and 116 of 200 (58·0%) patients were not covered by the perioperative prophylactic antibiotic. MDR was found in 102 of 147 (69·4%) patients for whom data were available to determine MDR status. Adjusted analysis found that appropriate prophylactic antibiotic coverage (adjusted odds ratio 0·43, 95% CI 0·19-0·96) and regular availability of infection control teams (0·32, 0·11-0·93) were associated with a significant reduction in MDR. INTERPRETATION Targeted perioperative antibiotic prophylaxis during contaminated abdominal surgery is insufficient in LMICs, with very few SSI organisms undergoing formal diagnosis. Expansion of testing capacity, development of local guidelines, and implementation of infection control teams could support the prevention of SSI through directed antibiotic prophylaxis, subsequently reducing the burden of MDR. FUNDING National Institute for Health and Care Research. TRANSLATIONS For the French and Spanish translations of the abstract see Supplementary Materials section.
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Kamarajah S, Ismail L, Ademuyiwa A, Adisa AO, Biccard B, Ghosh D, Galley F, Haque PD, Harrison E, Ingabire JCA, Kadir B, Lawani S, Ledda V, Lillywhite R, Martin J, de la Medina AR, Morton D, Nepogodiev D, Ntirenganya F, Omar O, Picciochi M, Tabiri S, Glasbey J, Bhangu A, Ademuyiwa A, Adisa AO, Bhangu A, Brant F, Brocklehurst P, Chakrabortee S, Ghosh D, Glasbey J, Gyamfi FE, Haque PD, Hardy P, Harrison E, Heritage E, Ingabire JCA, Ismail L, Kroese K, Lapitan C, Lillywhite R, Lissauer D, Magill L, de la Medina AR, Mistry P, Monahan M, Moore R, Morton D, Nepogodiev D, Ntirenganya F, Omar O, Pinkney T, Roberts T, Simoes J, Smith D, Tabiri S, Winkles N. Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial. Lancet Glob Health 2024:S2214-109X(24)00318-8. [PMID: 39245053 DOI: 10.1016/s2214-109x(24)00318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/19/2024] [Accepted: 07/18/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis. METHODS This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749. FINDINGS This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems. FUNDING National Institute for Health and Care Research Global Health Research Unit.
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Mengesha MG, Rajasekaran S, Ramachandran K, Sengodan VC, Yasin NF, Williams LM, Laubscher M, Watanabe K, Dastagir O, Akinmadr A, Fisseha HK, Aziz A, Yurac R, Gebrehana E, AlSaifi M, Pathinathan K, Sudhir G, Shokri AA, Chan Kim Y, Jonayed SA, Kido GR, Ignacio JM, Mohammed MS, Abubakar K, Hakim J, Duwal Shrestha SK, Al Mamun Choudhury A, Diallo M, Molina M, Patwardhan S, Hai Y, Ramat AM, Kawai M, Cho JH, Shah Kalawar RP, Choi SW, Zarate-Kalfopulos B, Guiroy A, Astur N, Buunaaim A, Human AL, Zaman AU. Orthopedic postoperative infection profile and antibiotic sensitivity of 2038 patients across 24 countries - Call for region and institution specific surgical antimicrobial prophylaxis. J Orthop 2024; 55:97-104. [PMID: 38681829 PMCID: PMC11047196 DOI: 10.1016/j.jor.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Improper utilization of surgical antimicrobial prophylaxis frequently leads to increased risks of morbidity and mortality.This study aims to understand the common causative organism of postoperative orthopedic infection and document the surgical antimicrobial prophylaxis protocol across various institutions in to order to strengthen surgical antimicrobial prophylaxis practice and provide higher-quality surgical care. Methods This multicentric multinational retrospective study, includes 24 countries from five different regions (Asia Pacific, South Eastern Africa, Western Africa, Latin America, and Middle East). Patients who developed orthopedic surgical site infection between January 2021 and December 2022 were included. Demographic details, bacterial profile of surgical site infection, and antibiotic sensitivity pattern were documented. Results 2038 patients from 24 countries were included. Among them 69.7 % were male patients and 64.1 % were between 20 and 60 years. 70.3 % patients underwent trauma surgery and instrumentation was used in 93.5 %. Ceftriaxone was the most common preferred in 53.4 %. Early SSI was seen in 55.2 % and deep SSI in 59.7 %. Western Africa (76 %) and Asia-Pacific (52.8 %) reported a higher number of gram-negative infections whereas gram-positive organisms were predominant in other regions. Most common gram positive organism was Staphylococcus aureus (35 %) and gram-negative was Klebsiella (17.2 %). Majority of the organisms showed variable sensitivity to broad-spectrum antibiotics. Conclusion Our study strongly proves that every institution has to analyse their surgical site infection microbiological profile and antibiotic sensitivity of the organisms and plan their surgical antimicrobial prophylaxis accordingly. This will help to decrease the rate of surgical site infection, prevent the emergence of multidrug resistance and reduce the economic burden of treatment.
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Affiliation(s)
| | - Shanmuganathan Rajasekaran
- Department of Orthopedics and Spine Surgery, Ganga Medical Centre and Hospital Pvt. Ltd., Mettupalayam Road, Coimbatore, India
| | - Karthik Ramachandran
- Department of Orthopedics and Spine Surgery, Ganga Medical Centre and Hospital Pvt. Ltd., Mettupalayam Road, Coimbatore, India
| | | | - Nor Faissal Yasin
- Natioal Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Orthopaedic Surgery Department, Faculty of Medicine, Universiti Malaya, Malaysia
| | | | - Maritz Laubscher
- Orthopaedic Research Unit (ORU), University of Cape Town, South Africa
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Japan
| | - O.Z.M. Dastagir
- National Institute of Traumatology and Orthopaedic Rehabilitation, Dhaka, Bangladesh
| | | | | | - Amer Aziz
- Orthopaedic & Spine Unit at Lahore Medical & Dental College / Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Ratko Yurac
- Department of Orthopedics and Traumatology, Universidad Del Desarrollo (UDD). Clinica Alemana de Santiago, Chile
| | - Ephrem Gebrehana
- Hawassa University College of Medicine and Health Sciences, Ethiopia
| | | | | | - G. Sudhir
- Sri Ramachandra Institute of Higher Education and Research, India
| | | | - Yong Chan Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, Seol, South Korea
| | - Sharif Ahmed Jonayed
- National Institute of Traumatology and Orthopaedic Rehabilitation, Dhaka, Bangladesh
| | - Gonzalo R. Kido
- Orthopaedic and Traumatology Department, Institute of Orthopedics “Carlos E. Ottolenghiâ€, Hospital Italiano de Buenos Aires, Argentina
| | - Jose Manuel Ignacio
- Department of Orthopedics, University of the Philippines Manila, Manila, Philippines
| | | | | | - Jonaed Hakim
- BIRDEM General Hospital & Ibrahim Medical College, Bangladesh
| | | | | | | | - Marcelo Molina
- Instituto Traumatológico de Santiago, Universidad Finis Terrae, Chile
| | - Sandeep Patwardhan
- Dept. of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India
| | - Yong Hai
- Beijing Chaoyang Hospital, Capital Medical University, China
| | - Ali M. Ramat
- University of Maiduguri Teaching Hospital, Nigeria
| | - Momotaro Kawai
- Department of Orthopaedic Surgery, Spine Center, Kitasato Institute Hospital, Japan
| | - Jae Hwan Cho
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | | | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, South Korea
| | | | | | - Nelson Astur
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | | | - Atiq Uz Zaman
- Ghurki Trust Teaching Hospital/Lahore Medical and Dental College, Pakistan
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Hurisa Dadi H, Habte N, Mulu Y. Length of hospital stay and associated factors among adult surgical patients admitted to surgical wards in Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia. PLoS One 2024; 19:e0296143. [PMID: 39133738 PMCID: PMC11318930 DOI: 10.1371/journal.pone.0296143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 07/23/2024] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION Hospitals across the country are facing increases in hospital length of stay ranging from 2% to 14%. This results in patients who stay in hospital for long periods of time being three times more likely to die in hospital. Therefore, identifying factors that contribute to longer hospital stays enhances the ability to improve services and quality of patient care. However, there is limited documented evidence on factors associated with longer hospital stays among surgical inpatients in Ethiopia and the study area. OBJECTIVE This study aimed to assess the length of hospital stay and associated factors among adult surgical patients admitted to surgical wards in Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia, 2023. METHODS An institutional-based cross-sectional study was conducted among 452 adult surgical patients from April 17 to May 22, 2023. Data were collected based on a pretested, structured, interviewer-administered questionnaire, medical record review, and direct measurement of BMI. Study participants were selected using a systematic random sampling technique. The collected data were cleaned, entered into EpiData version 4.6.0 and exported to STATA version 14 for analysis. Binary logistic regression analysis was used. Variables with a p value <0.05 in the multivariable logistic regression analysis were considered statistically significant. RESULTS In the current study, the prevalence of prolonged hospital stay was 26.5% (95% CI: 22.7, 30.8). Patients referred from another public health facility (AOR = 2.65; 95% CI: 1.14, 6.14), hospital-acquired pneumonia (AOR = 3.64; 95% CI: 1.43, 9.23), duration of surgery ≥110 minutes (AOR = 2.54; 95% CI: 1.25, 5.16), being underweight (AOR = 5.21; 95%CI: 2.63, 10.33) and preoperative anemia (AOR = 3.22; 95% CI: 1.77, 5.86) were factors associated with prolonged hospital stays. CONCLUSION This study found a significant proportion of prolonged hospital stays among patients admitted to surgical wards. Patients referred from another public health facility, preoperative anemia, underweight, duration of surgery ≥110 minutes, and hospital-acquired pneumonia were factors associated with prolonged hospital stay. Early screening and treatment of anemia and malnutrition before surgery can shorten the length of stay.
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Affiliation(s)
- Habtamu Hurisa Dadi
- Department of Surgical Nursing, School of Nursing, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Netsanet Habte
- Department of Adult Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yenework Mulu
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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8
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Laäs DJ, Naidoo M. Perioperative antithrombotic medication: An approach for the primary care clinician. Afr J Prim Health Care Fam Med 2024; 16:e1-e7. [PMID: 39221731 PMCID: PMC11369573 DOI: 10.4102/phcfm.v16i1.4555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 09/04/2024] Open
Abstract
The primary care clinician faces many challenges and is often left to manage complex pathology because of resource constraints at higher levels of care. One of these complex conditions is the perioperative management of antithrombotic medication. This narrative review is focused on helping the clinician navigate the complex path and multiple guidelines related to the perioperative use of antithrombotic medication. Perioperative antithrombotic guidelines (American College of Chest Physicians, European Society of Regional Anaesthesia, and American Society of Regional Anesthesia) and relevant publications were identified by a PubMed search using the terms perioperative AND anticoagulants OR antithrombotics AND guideline. Issues relevant to clinical practice were identified, and attempts were made to explain any ambiguity that arose. Adhering to basic pharmacological principles and evidence-based guidelines allows for the safe usage of antithrombotics. Knowing when to stop, continue, bridge and restart antithrombotic medication prevents perioperative morbidity and mortality. Stopping antithrombotic medication too early can lead to thromboembolic complications associated with their primary disease process. Not stopping antithrombotic medication or stopping it too late can potentially cause life-threatening bleeding, haematomas and increased transfusion requirements.
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Affiliation(s)
- Daniël J Laäs
- Department of Anaesthesia and Critical Care, Faculty of Health Science, University of KwaZulu-Natal, Durban.
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9
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Van Der Merwe Z, Wilton SD, Sandy-Hodgetts K. Risk factors associated with surgical site infection following orthopaedic surgery in South Africa and Sub-Saharan Africa: a scoping review protocol. J Wound Care 2024; 33:S4-S8. [PMID: 39140712 DOI: 10.12968/jowc.2024.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
OBJECTIVE The objective of the scoping review will be to understand and describe risk factors associated with surgical site infection (SSI) in an orthopaedic surgery population in Sub-Saharan Africa and South Africa. This paper describes the protocol that will be used for the scoping review. METHOD A comprehensive literature search will be conducted using MEDLINE (PubMed), CINAHL (EBSCO), Embase and Cochrane Libraries to identify articles meeting the inclusion criteria, including both published and grey literature, in order to provide a broad overview of the reported risk factors associated with patients who have undergone an orthopaedic surgery with an outcome of SSI within 90 days of a procedure. Additional studies will be sourced by exploring the reference list of included eligible studies. By using a combination of the Population, Exposure, Outcome framework, terms and synonyms related to each category, in different variations, along with Boolean operators (AND, OR, NOT) in the search strategy, identified comprehensive and relevant literature for the scoping review. RESULTS It is anticipated the results will provide a baseline of risk factors that will inform the development of a risk assessment tool for clinical use. CONCLUSION This protocol will inform the development of a scoping review to describe factors associated with SSIs following orthopaedic surgery in Sub-Saharan Africa and South Africa.
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Affiliation(s)
| | - Steve D Wilton
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Perth, Western Australia
- Perron Institute for Neurological and Translational Science, The University of Western Australia, Nedlands, Western Australia
| | - Kylie Sandy-Hodgetts
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Perth, Western Australia
- Senior Research Fellow, School of Biomedical Sciences, University of Western Australia
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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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11
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Evans FM, Enright AC. Anesthesia Workforce Numbers: Only Part of the Story. Anesth Analg 2024; 139:1-3. [PMID: 38885394 DOI: 10.1213/ane.0000000000006950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
- Faye M Evans
- From the Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, Massachusetts
| | - Angela C Enright
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
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Mulugeta H, Zemedkun A, Mergia G, Abate SM, Gebremariam M, Jemal B, Nenko G, Gebremichael G, Besha A, Aregu MB. Perioperative capacity and contextual challenges in teaching hospitals of southern Ethiopia: explanatory sequential mixed-methods research. Perioper Med (Lond) 2024; 13:61. [PMID: 38909267 PMCID: PMC11193207 DOI: 10.1186/s13741-024-00423-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 06/18/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Previous Ethiopian literature on surgical capacity and challenges has focused on quantitative investigations, lacking contextual understanding. This explanatory sequential mixed-methods research (MMR) aimed to assess perioperative capacity and contextual challenges at three teaching hospitals in southern Ethiopia. METHODS A quantitative survey assessed workforce, infrastructure, service delivery, financing, and information systems. The survey findings were explained by qualitative semi-structured interviews of twenty perioperative providers. Descriptive statistics were integrated with qualitative thematic analysis findings using the narrative waving approach. Key findings from both datasets were linked using a joint display table. RESULTS The survey revealed shortages in the specialist workforce (with a ratio of 0.58 per 100,000 population), surgical volume (at 115 surgeries per 100,000 population), equipment, supplies, financing, and perioperative data tracking. Hospitals' radiology services and blood products were only available 25-50% of the time, while anesthetic agents and essential laboratory services were often available 51-75% of the time. Perioperative management protocols were used rarely (1-25% of the time). Over 90% of patients lack health insurance coverage. Qualitative data also revealed scarcity of perioperative resources and equipment; unaffordable perioperative costs, lack of health insurance coverage, and unforeseen expenses; poor patient safety culture and communication barriers across the perioperative continuum of care; workforce shortages, job dissatisfaction, and concerns of competence; and weak national governance, and sociopolitical turmoil, and global market volatility exacerbating local challenges. These challenges are linked to risks in quality of care and patient safety, according to clinicians. CONCLUSION The study identifies deficiencies in the health system and sociopolitical landscape affecting safe surgery conduct. It highlights the need for comprehensive health system strengthening to expand workforce, upgrade facilities, improve safety culture, resilience, and leadership to ensure timely access to essential surgery. Exploring external factors, such as the impact of national governance and sociopolitical stability on reform efforts is also essential.
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Affiliation(s)
- Hailemariam Mulugeta
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia.
| | - Abebayehu Zemedkun
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Getachew Mergia
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Semagn M Abate
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Mintesnot Gebremariam
- Department of Surgery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Bedru Jemal
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Getachew Nenko
- Department of Healthcare Leadership and Management, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Genet Gebremichael
- Department of Nursing, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Aschalew Besha
- Department of Anesthesia and Critical Care, School of Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Mekonnen B Aregu
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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13
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Shah V, Hassan B, Hassan R, Alexis M, Bhoopalam M, Agandi L, Liang F. Gender-Affirming Surgery in Low- and Middle-Income Countries: A Systematic Review. J Clin Med 2024; 13:3580. [PMID: 38930109 PMCID: PMC11205133 DOI: 10.3390/jcm13123580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: Fewer than one-fifth of all studies on gender-affirming care originate from low- and middle-income countries (LMICs). This is the first systematic review to examine surgical demographics and outcomes following gender-affirming surgery (GAS) in LMICs. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, five databases were systematically searched for original studies and case series on GAS within LMIC settings. Excluded reports included animal studies, non-English language studies, secondary studies including reviews, individual case reports and conference abstracts. Results: This review includes 34 studies involving n = 5064 TGNB individuals. Most studies (22, 64.7%) were from upper-middle-income countries, followed by lower-middle-income countries (12, 35.3%). A total of 31 studies (91.2%) reported on post-operative outcomes. Of n = 5013 patients who underwent GAS, 71.5% (n = 3584) underwent masculinizing and 29.5% (n = 1480) underwent feminizing procedures. The predominant procedures were metoidioplasty (n = 2270/3584, 63.3%) and vaginoplasty (n = 1103/1480, 74.5%). Mean follow-up was 47.7 months. In patients who underwent metoidioplasty, 6.8% (n = 155) of patients experienced a complication and 6.3% (n = 144) underwent revision surgery. In patients who underwent vaginoplasty, 11.5% (n = 127) of patients experienced a complication and 8.5% (n = 94) underwent revision surgery. Of the studies (25/34, 73.5%) that reported on quality of life and post-operative satisfaction, the majority showed marked improvements in psychosocial and functional outcomes. Notably, no post-surgical regret was reported among the surveyed patients. Conclusions: Existing literature on GAS in LMICs remains scarce and is concentrated in select institutions that drive specific procedures. Our review highlights the low reported volumes of GAS, variability in surgical outcomes and quality of life.
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Affiliation(s)
- Viraj Shah
- Faculty of Medicine, Imperial College London, London SW10 9NH, UK;
| | - Bashar Hassan
- Johns Hopkins Medicine, Baltimore, MD 21287, USA; (B.H.); (M.B.)
- Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Rena Hassan
- Faculty of Medicine, Saint Georges University of Beirut, Beirut 2807, Lebanon;
| | - Malory Alexis
- Florida State University College of Medicine, Tallahassee, FL 32301, USA;
| | - Myan Bhoopalam
- Johns Hopkins Medicine, Baltimore, MD 21287, USA; (B.H.); (M.B.)
| | - Lorreen Agandi
- Touro College of Osteopathic Medicine, New York, NY 10027, USA;
| | - Fan Liang
- Johns Hopkins Medicine, Baltimore, MD 21287, USA; (B.H.); (M.B.)
- Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
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14
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McCulloch P, Martin J. IDEAL evaluation for global surgery innovation. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2024; 6:e000297. [PMID: 38883695 PMCID: PMC11177697 DOI: 10.1136/bmjsit-2024-000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 06/18/2024] Open
Affiliation(s)
- Peter McCulloch
- Nuffield Department of Surgical Science, University of Oxford, Oxford, UK
| | - Janet Martin
- Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- MEDICI Centre, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Gerber C, Bishop DG, Dyer RA, Maswime S, Rodseth RN, van Dyk D, Kluyts HL, Mbwele B, Tumukunde JT, Madzimbamuto FD, Elkhogia AM, Ndonga AK, Ngumi ZWW, Omigbodun AO, Amanor-Boadu SD, Zoumenou E, Basenero A, Munlemvo DM, Coulibaly Y, Ndayisaba G, Antwi-Kusi A, Gobin V, Forget P, Rakotoarison S, Samateh AL, Mehyaoui R, Patel-Mujajati U, Sani CM, Madiba TE, Pearse RM, Biccard BM. Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study. Anesth Analg 2024; 138:1275-1284. [PMID: 38190343 DOI: 10.1213/ane.0000000000006750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.
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Affiliation(s)
- Carmen Gerber
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - David G Bishop
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Robert A Dyer
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- World Federation of the Societies of Anaesthesiologists Obstetric Anaesthesia Committee, London, United Kingdom
| | - Salome Maswime
- Division of Global Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Reitze N Rodseth
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Dominique van Dyk
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, South Africa
| | - Bernard Mbwele
- Department of Epidemiology, Biostatistics and Clinical Research, University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Mbeya, Tanzania
| | | | - Farai D Madzimbamuto
- Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Abdulaziz M Elkhogia
- Department of Anaesthesia and Intensive Care, Tripoli University Hospital, Tripoli, Libya
| | - Andrew K Ndonga
- Department of General and Gastrosurgery, Mater Hospital, Nairobi, Kenya
| | - Zipporah W W Ngumi
- Department of Anaesthesia, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Akinyinka O Omigbodun
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Eugène Zoumenou
- Department of Surgery, Clinique Universitaire Polyvalente d'Anesthésie-Réanimation Centre National Hospitalier et Universitaire HKM de Cotonou, Cotonou, Benin
| | - Apollo Basenero
- Quality Management Programme, Ministry of Health and Social Services Namibia, Windhoek, Namibia
| | - Dolly M Munlemvo
- Department of Anaesthesia, University Hospital of Kinshasha, Kinshasha, Democratic Republic of Congo
| | - Youssouf Coulibaly
- Service des urgences, d'anesthésie et de Réanimation polyvalente, Faculté de médicine de Bamako, Bamako, Mali
| | - Gabriel Ndayisaba
- Department of Surgery, Kamenge Teaching Hospital, Bujumbura, Burundi
| | - Akwasi Antwi-Kusi
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Veekash Gobin
- Department of Anaesthesia, Ministry of Health and Quality of Life, Jawaharlal Nehru Hospital, Rose Belle, Mauritius
| | - Patrice Forget
- Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Department of Anaesthesia, NHS Grampian, Aberdeen, United Kingdom
| | | | - Ahmadou L Samateh
- Department of Surgery, Edward Francis Small Teaching Hospital, Banjul, The Gambia
| | - Ryad Mehyaoui
- Department of Anesthesiology and Intensive Care in Cardiovascular Surgery, Algiers University, Algiers, Algeria
| | | | - Chaibou M Sani
- Department of Anesthesiology, Intensive Care and Emergency, National Hospital of Niamey, Niamey, Republic of Niger
| | | | - Rupert M Pearse
- Critical Care and Perioperative Medicine Research Group, Queen Mary University of London, United Kingdom
| | - Bruce M Biccard
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
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Jackman JM, Yibrehu B, Doyle A, Alatise OI, Wuraola FO, Olasehinde O, Peter Kingham T. Updates in global oncology: Advancements and future directions. J Surg Oncol 2024; 129:1374-1383. [PMID: 38624014 DOI: 10.1002/jso.27633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 04/17/2024]
Abstract
Globally, cancer is the second leading cause of death, and low- and middle-income countries bear most of the disease burden. While cancer is increasingly recognized as a major global health issue, more work remains. Understanding the status of global cancer care will shape the next steps in ensuring equitable global access to cancer care. This article highlights ongoing initiatives in global oncology and the next steps in advancing the field.
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Affiliation(s)
- Julia M Jackman
- Global Cancer Disparities Initiative, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Betel Yibrehu
- Global Cancer Disparities Initiative, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Alex Doyle
- Global Cancer Disparities Initiative, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Caribbean Colon Cancer Initiative, Bridgetown, Barbados
| | - Olusegun Isaac Alatise
- Surgery Department, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Olalekan Olasehinde
- Surgery Department, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - T Peter Kingham
- Global Cancer Disparities Initiative, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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17
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Nepogodiev D, Ismail L, Meara JG, Roslani AC, Harrison EM, Bhangu A. Strengthening health systems through surgery. Lancet 2024; 403:2358-2360. [PMID: 38782001 DOI: 10.1016/s0140-6736(24)01031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Dmitri Nepogodiev
- NIHR Global Health Research Unit on Global Surgery, Institute of Applied Health Research, Institute of Translational Medicine, University of Birmingham, Birmingham B15 2TH, UK.
| | - Lawani Ismail
- Department of Visceral Surgery, University of Abomey-Calavi Faculty of Health Sciences, Cotonou, Benin
| | - John G Meara
- Program in Global Surgery and Social Change and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - April C Roslani
- Department of Surgery, University Malaya Medical Centre and Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Ewen M Harrison
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Aneel Bhangu
- NIHR Global Health Research Unit on Global Surgery, Institute of Applied Health Research, Institute of Translational Medicine, University of Birmingham, Birmingham B15 2TH, UK
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18
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Awedew AF, Asefa Z. Gastrointestinal Surgical Outcomes Study (GISOS): a 30-day monocentric prospective cohort study in Ethiopia. BMJ Open 2024; 14:e084280. [PMID: 38803246 PMCID: PMC11129042 DOI: 10.1136/bmjopen-2024-084280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE The impact of perioperative mortality and morbidity extends globally, playing substantial roles in mortality rates, levels of disability and economic consequences. This study was primarily designed to provide insights into the surgical outcomes of gastrointestinal surgeries carried out in a high-volume centre in Ethiopia in the year 2023. DESIGN A 30-day prospective cohort observational study employed. SETTING High volume surgical specialised hospital in Ethiopia. PARTICIPANTS All adult patients who had abdominal surgery. OUTCOME MEASURES 30th-day postoperative mortality and complications. RESULTS During this prospective observational study, data from 259 patients were collected. This prospective observational study found that 30-day complication rate was 30.5%. Surgical site infection is the leading complications (15.8%) followed by postop acute kidney injury (9.3%). Malignant pathology (adjusted OR (AOR)=1.43 (1.01 to 3.06); p=0.035, ASA III (AOR=4.00 (1.01 to 16.5); p=0.049), ECOG III (AOR=2.8 (1.55 to 7.30); p=0.025) and comorbidity (AOR=2.02 (1.02 to 3.18); p=0.008) had statistically significant association with 30-day complication rates. We also found that a 30-day mortality rate was 14.3%. Emergency surgery (AOR=5.53 (1.4 to 21.6); p=0.014), Eastern Cooperative Oncology Group III (AOR=8.6 (1.01 to 74.1); p=0.0499), American Society of Anesthesiology III (AOR=12.7 (1.9 to 85.5); p=0.009) and comorbidity (AOR=7.5 (1.4 to 39.1); p=0.017) had statistical significance association with a 30-day mortality rate after gastrointestinal surgery. CONCLUSION The findings of this study indicated that postoperative mortality and complications were alarmingly high, which highlights the need for innovative solutions to lower postoperative mortality and complications.
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Affiliation(s)
| | - Zelalem Asefa
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
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19
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Wu CL. 2024 Gaston Labat Award Lecture-outcomes research in Regional Anesthesia and Acute Pain Medicine: past, present and future. Reg Anesth Pain Med 2024; 49:307-312. [PMID: 38395462 DOI: 10.1136/rapm-2024-105286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Christopher L Wu
- Department of Anesthesiology, Critical Care Medicine and Pain Management, Hospital for Special Surgery, New York, New York, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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20
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Nizeyimana F, Skelton T, Bould MD, Beach M, Twagirumugabe T. Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda. Anesth Analg 2024; 138:1063-1069. [PMID: 37678238 DOI: 10.1213/ane.0000000000006641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Despite an increasing awareness of the unmet burden of surgical conditions, information on perioperative complications in children remains limited especially in low-income countries such as Rwanda. The objective of this study was to estimate the prevalence of perioperative anesthesia-related adverse events and to explore potential risk factors associated with them among pediatric surgical patients in public referral hospitals in Rwanda. METHODS Data were collected for all patients under 5 years of age undergoing surgery in 3 public referral hospitals in Rwanda from June to December 2015. Patient and family history, type of surgery, comorbidities, anesthesia technique, intraoperative adverse events and postoperative events in the postanesthesia care unit (PACU) were recorded. The incidence of perioperative adverse events was assessed and associated risk factors analyzed with univariate logistic regression. RESULTS Of 354 patients enrolled in this study 11 children had a cardiac arrest. Six (1.7%) suffered an intraoperative cardiac arrest, 2 of whom (0.6%) died intraoperatively. In the PACU, 6 (1.8%) suffered a postoperative cardiac arrest, 5 of whom (1.5%) died in the PACU. One child had both an intraoperative cardiac arrest and then a cardiac arrest in PACU but survived. Eighty-nine children (25.1%) had an intraoperative adverse event, whereas 67 (20.6%) had an adverse event in PACU. A review of the cases where cardiac arrest or death occurred indicated that there were significant lapses in the expected standard of care. Age <1 week was associated with cardiac arrest or death. CONCLUSIONS The rate of perioperative complications, including death, for children undergoing surgery in tertiary care hospitals in Rwanda was high. Quality improvement measures are needed to decrease this rate among surgical pediatric patients in this low resource setting.
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Affiliation(s)
- Francoise Nizeyimana
- From the Department of Anesthesia and Critical Care, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Teresa Skelton
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M Dylan Bould
- Department of Anesthesiology, The Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Beach
- Department of Anesthesiology, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Theogene Twagirumugabe
- Department of Anaesthesiology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Anesthesiology and Pain Medicine, Critical Care and Emergency Medicine, University of Rwanda, Butare, Rwanda
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21
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Dessalegn M, Negesse A, Deresse T, Yigzaw Birhanu M, Agedew E, Dires G. Perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: 2023: retrospective follow-up study. BMC Surg 2024; 24:114. [PMID: 38627671 PMCID: PMC11020798 DOI: 10.1186/s12893-024-02401-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Emergency laparatomy is abdominal surgery associated with a high rate of mortality. There are few reports on rates and predictors of postoperative mortality, whereas disease related or time specific studies are limited. Understanding the rate and predictors of mortality in the first 30 days (perioperative period) is important for evidence based decision and counseling of patients. This study aimed to estimate the perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia, 2023. METHODS This was a Hospital-based retrospective follow-up study conducted at Debre Markos Comprehensive Specialized Hospital in Ethiopia among patients who had undergone emergency laparatomy between January 1, 2019 and December 31, 2022. Sample of 418 emergency laparatomy patients selected with simple random sampling technique were studied. The data were extracted from March 15, 2023 to April 1, 2023 using a data extraction tool, cleaned, and entered into Epi-Data software version 3.1 before being exported to STATA software version 14.1 for analysis. Predictor variables with P value < 0.05 in multivariable Cox regression were reported. RESULTS Data of 386 study participants (92.3% complete charts) were analyzed. The median survival time was 18 days [IQR: (14, 29)]. The overall perioperative mortality rate in the cohort during the 2978 person-days of observations was 25.5 per 1000 person-days of follow-up [95% CI: (20.4, 30.9))]. Preoperative need for vasopressor [AHR: 1.8 (95% CI: (1.11, 2.98))], admission to intensive care unit [AHR: 2.0 (95% CI: (1.23, 3.49))], longer than three days of symptoms [AHR: 2.2 (95% CI: (1.15, 4.02))] and preoperative sepsis [AHR: 1.8 (95% CI: (1.05, 3.17))] were identified statistically significant predictors of perioperative mortality after emergency laparatomy. CONCLUSIONS The perioperative mortality rate is high. Preoperative need for vasopressors, admission to intensive care unit, longer than three days of symptoms and preoperative sepsis were predictors of increased perioperative mortality rate.
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Affiliation(s)
- Megbar Dessalegn
- Department of Surgery, School of Medicine, Debre Markos University, Debre Markos, Ethiopia.
| | - Ayenew Negesse
- Department of Human Nutrition, Health Science College, Debre Markos University, Debre markos, Ethiopia
| | - Tilahun Deresse
- Department of Surgery, School of Medicine, Debre Birhan University, Debre Markos, Ethiopia
| | - Molla Yigzaw Birhanu
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Eskeziyaw Agedew
- College of Health Sciences, Debre Markos University, Debre markos, Ethiopia
| | - Gedefaw Dires
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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22
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Ng-Kamstra JS, Philipo GS, Obayagbona KI. Paediatric surgery outcomes in Africa: a call for urgent investment. Lancet 2024; 403:1425-1427. [PMID: 38527481 DOI: 10.1016/s0140-6736(24)00320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 02/16/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Surgery, Massachusetts General Hospital, Boston 02114, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA; Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
| | - Godfrey Sama Philipo
- The College of Surgeons of East Central and Southern Africa (COSECSA), Arusha, Tanzania; The Branch for Global Surgical Care, University of British Columbia, Vancouver, BC, Canada
| | - Kate Isoken Obayagbona
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
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23
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Torborg A, Meyer H, El Fiky M, Fawzy M, Elhadi M, Ademuyiwa AO, Osinaike BB, Hewitt-Smith A, Nabukenya MT, Bisegerwa R, Bouaoud S, Abdoun M, El Adib AR, Kifle Belachew F, Gebre M, Taye DB, Kechiche N, Fadalla T, Abdallah B, Chaibou MS, Nyarko MYA, Ki KB, Shalongo S, Mulwafu W, Thomson E, Traore MM, Ndonga A, Bittaye M, Samateh AL, Munlemvo DM, Kalongo JJ, Coulibaly Y, Coulibaly Y, Ravelojaona V, ANDRIAMANARIVO L, RAHERISON AR, RANDRIAMIZAO HMR, RAMKALAWAN K, Omar MA, Ndikontar R, Joseph D, Dahir S, Mohamed M, Ali Daoud H, Ndarukwa P, OTIOBANDA GF, Banguti P, Neil K, Derbew M, Fanny M, Smalle I, Taylor EH, Duvenage H, Hardy A, Kluyts H, Pearse R, Biccard B, AARON OI, Abd Elazeem Mohammed HAS, Abdalkarim B, Abdalla A, Abdallah MAA, Abdeewi S, Abdel Ghafar T, Abdelaleem A, Abdelaleem IA, Abdelgader K, Abdelgadir W, Abdelhafez M, Abdelhalim A, Abdelkabir M, Abdelkader Osman M, Abdelkarim M, Abdelkarim M, Abdelmohsen SM, Abdelnassir M, Abdelrahman ASM, Abdelwahed AE, Abdelzaher M, Abderrahim BA, Abdoulaye T, Abdulai S, Abdulghaffar YA, Abdullah F, Abdullahi LB, Abdullahi M, Abdulrazik S, Abdulsalam KI, Abdulwahed E, Abdus-Salam R, ABE TOLUSHE, Abera Mulugeta G, Aboelghait AA, Abol Oyoun N, Aboubekr B, Abraham M, Abu M, Abuagila AA, Abubakar M, Abugilah M, Abuzeid IA, Achouri D, Acquah SA, Adam NBA, ADAMU AUWAL, Adamu KM, ADAMU MUHAMMAD, ADAMU S, Adane SG, Adeaga M, Adebayo S, Adedire A, Adegoke PA, Ademuyiwa AO, Adeniyi AA, Adeoye I, Aderibigbe G, ADEROUNMU A, ADEYEMI WILLIAMS, ADEYEMO A, Adigun T, Adika ED, ADISA AO, Adjei E, Adjepong-Tandoh EK, Ads AM, ADUMAH DCC, ADUMAH LO, Adzamli I, Afari J, Afedo W, Affan A, AFOLAYAN AO, Agaba S, Agbeno E, Agbonrofo P, Aghadi I, AGU EDITH, Agyen T, Agyen-Mensah K, Ahensan D, Ahmad MH, AHMED A, Ahmed L, Ahmed NYAA, Ahmed R, Ahmed Jroush M, ahmed maghur H, AHOGNI GG, Ait Yahia S, Aji N, Aji SA, Akerele W, Akhideno I, Akinmokun I, AKINNIYI AT, Akinniyi A, AKINYEMI S, Akitoye OA, AKPAETTE IC, Akuma TJ, Akuokor D, Akwei CNA, Al Bashir RBH, Al Gharyani MF, al Islam ben Jouira R, Aladelusi T, Alakaloko F, Alameen H, Alameen Moheyaldeen M, Alaogaly M, Alarabi R, Alawami M, Alazabi BM, Alazabi M, Albakosh BA, ALBDULRRAZIQ HUSAYNMOHAMMEDE, Aldieb A, Aldressi W, Alegbeleye GE, Alfa Y, Alhadad Q, Alhaddad AR, Alhaddad HF, Alhadi A, Alhamali A, Alharam A, Alhlafi M, Alhouwasi B, Alhudhairy S, Ali AMA, Ali AJ, Ali A, Ali A, Ali E, Ali M, Ali S, Ali YY, Ali Ahmed A, Aliozor S, Aljamal S, Alkaseek A, Alkhalifa E, Alkoni S, Allie A, Almelyan K, Almugaddami A, Almujreesi A, Alqady E, Alragheai AA, Alshareea E, Alshareef A, Alsori M, Altomy SA, Al-Touny A, Al-Touny SA, Alum Aguma R, Alwaer NM, Al-zletni H, Alzwai M, Amaambo N, Amah CC, Amary M, Amengle LA, Amesho SLO, Ametepe M, Amkhatirah E, Amnaina MG, Amoah B, Amoah JK, Amo-Aidoo NAS, Amoako-Boateng M, Ampong J, Anane-Fenin B, Anarfi S, Andriamanarivo ML, Aniakwo L, Aniteye E, Ankrah LNA, Anno A, Anyanwu LJC, Anyigba E, Appeadu-Mensah W, Appiah-Thompson P, Apraku-Peprah EL, Aremu SK, Arinaitwe M, Armah R, Arthur A, Arthur D, Asah-Opoku K, Asante M, Asante-Asamani A, Asare A, Asasira L, Ashfersh M, ASHINDOITIANG JA, Ashong J, Ashraf Salah M, Asiedu C, Asiedu I, Asiyanbi K, Asla A, Asman W, Asoegwu EJ, Assalhi M, Assim C, Asudo FD, Atai AG, Ateeqa SB, Atim T, Atindama S, ATIQUI IJLAL, Atrih Z, Attah RA, Awad AK, Awedew AF, Awedew AF, Aween H, Awere-Kyere L, Awindaogo J, Awori Achani M, Ayad K, Azab A, Azas A, Aziza B, Azize DA, AZOUI A, Azouz J, Baba S, Babalola OF, Babiker M, Baddoo D, Badi A, BADMUS SA, Badr H, Bah A, Bah FY, Bah K, Bah MT, Bahroun S, Baidoo E, Baidoo K, Baidoo R, Bakare A, Bakeer HB, Baky Fahmy MA, Balogun J, Bamigboye B, Bankah P, Banson M, Barhouma YE, Barongo M, BASHIR RABIU MOHAMMED, Bassem A, Bedair MAA, Beeharry HR, Beeharry S, Bekele S, Belie O, Belkhair A, Ben Ahmed Y, Ben Ashur A, Ben Hamida B, Benade C, BENMANSEUR S, Bensebti AA, BERDAI MA, Beyuo V, Biala M, Bilson-Amoah E, Bin wali SS, Binnawara M, Birlie Chekol W, Birqeeq 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Human T, Hussain E, Hussain Kona MH, Hussein Y, Ibekwe TS, Ibiyemi A, IBIYEYE TAIBAT, Ibrahim IA, Ibrahim LI, Ibrahim S, Ibrahim Abubakar A, Ibrahim Alain T, Idipo F, Idoko G, Idowu O, Idris MEA, Igaga EN, Iindongo E, IITULA P, IKOTUN O, ILLE G, Imposo DH, Invernizzi J, Irungu E, Isbayqah AM, Isbayqah EM, Ismael G, Ismail AM, Itambi AM, Jabang JN, Jaga R, Jaganath U, Jaiteh L, Jallow CS, James O, Javed S, Jithoo S, Jlidi S, Joel L, Johnson M, JONES TAIWO, Jooma Z, Joomye S, Joosab M, JOUINI R, Jubail MJ, Juggoo C, Jumbi TM, Kaabar N, Kabirou M, Kabiru AM, Kabre BY, Kache S, Kacimi SEO, KADAS ABUBAKARSAIDU, KAHANSIM B, Kalipa M, Kalongo JJK, Kalu NE, Kamate B, Kamwangen GM, Kandjimi M, Kanjana-Zondo N, Kankpeyeng L, Kapalamula T, Karadji S, Kargbo MA, Karghul M, Kaskar R, Kasker R, Kasobya F, Kassem O, Kateregga G, Kayima P, Kedwany AM, Ken-Amoah S, Kenneth TK, KERISSE ANEH, KERKENI Y, Khairi R, Khaled M, Khalifa E, Khalifa MS, Khalil MK, Khattab MSI, Khodary AR, Khumalo BF, Khumalo P, Kigayi JP, Kimutai TK, KINDO B, KIRFI ABDULLAHIMUSA, Koggoh P, Koko AA, Kopieniak M, Kotagiri C, Kotey E, Kouicem AT, Kpangkpari R, Kudoh V, Kufonya N, Kuhn W, Kutor J, Kwakye A, Kynes JM, Lambrechts L, Lamiri R, LANRE OLOKONASIRUDEEN, Larvie P, Lateef AK, LATRECHE S, Lawal T, Leballo G, Lebereki S, Lee D, Leeb G, Leonard T, LEYONO-MAWANDZA PDG, Likongo TB, Limalia Z, LIMAN HARUNAUSMAN, Loae N, Lompoli BNE, Lusungu D, M.Mokhtar FALZ, Madany MEDM, Maddy RJ, Madombwe G, Mafabi S, Magashi MK, Maharaj S, Mahfouz SM, Mahlare KRV, Mahmoud F, Maikassoua M, Maison P, Maiwald D, Makhoba P, Makinita SG, Makou epse Tolefac M, Malau TK, Mamathuntsha TG, Mamo TN, Mamuda A, Mandundzo P, Mangray H, Mani S, Manneh EK, Mansour NM, Manyere DV, Mapurisa A, Mare P, Martin ME, Mashaal A, Mashaya S, Masilela PB, Mathebula R, Mathinya T, Matlala TK, Matlou M, Matos-Puig R, Matoug S, Maudarbocus MJ, Mavesere HP, Mavila J, Mayet S, Maygag M, Mbatha N, Mbatudde R, Mbiya Kapinga A, Mbuyamba J, Mbuyi AT, Mdlalose N, Prowling M, Mejeni N, Mekonnen Ejigu Y, Merghani S, Metogo JEN, Mhiri R, Mhone L, Michael A, Miko AM, Milad A, Mishra R, Mjadu L, Mkhontwana N, Mlambo N, Mncwango Z, Mngoma G, Mnguni M, Modekwe VI, Mogane P, Moghazy R, Mogotsi K, Mohalal MS, Mohamed AAA, Mohamed M, Mohamed MEE, Mohamed SA, Mohamedkheir MA, Mohammad AL, Mohammad AD, Mohammad AM, Mohammed A, Mohammed M, Mohammed RI, Mohammed R, Mohammed TSA, Mohammedosman D, Mohsen SM, Molla Getahun A, Moloisi M, Monib FA, Moodley K, Moopanar M, Morgan F, Moris B, Morna M, Moses V, Mostafa MM, Motiang M, Motseoile T, Motshabi P, MOUSSAOUI N, Mpoto DB, MPOY EMY MONKESSA CM, MRARA BUSISIWE, Mshelbwala PM, Msherghi A, Msibi T, Mubunda RK, Muhammad AB, Muhammad S, Muhanguzi J, Muhindo R, Mukenga MM, Mukuna PM, Mulewa D, Munanzvi KS, Mungur L, Munubi A, Munyalo FS, Muriithi JM, Musa AA, Musa K, Musa MAE, Musana F, Musewu TD, Musiitwa AK, Mwangi CM, Mwepu IM, Mwepu MI, Mwika PM, Mwiti TM, Myeni P, Mzoneli N, Naana R, Nabukenya G, Nabunya S, Naidoo A, Naidoo V, Naidu P, Nakyanzi C, Nambi E, Nampawu MJ, Nampiina G, Namutebi H, Nana B, Nanda JSY, Nanimambi J, Nantongo B, Napolitano L, Naser A, Nassar AS, Nassar MS, Nasser N, Nawezo JG, NDIAYE A, NDIAYE CAT, Ndiaye F, Ndibarekera SH, Ndjoko SM, Ndlovu M, Nduwayezu R, Negash S, Nehema S, Neil K, Neizer M, NEJMI S, Nezam-Parast M, Ng How Tseung K, Ngcelwane T, Ngene I, Nghidinwa H, Ngissah R, Ngock GFFN, Ngouane D, Ngumi Z, Nibret Y, NIENGO OUTSOUTA G, Njie M, NJOKANMA RA, Nkhata L, Nkhuna NT, Nkosi N, Nkosi S, Nkwembe CM, Nnaji C, Nneji-Akazie T, Nongqo N, Nortey M, Noutakdie Tochie J, Nsaful J, Nsimire BB, Nte SK, Ntshingila C, Ntsie NP, Ntsoane D, Ntumy MY, Nuer-Allornuvor G, Nuhu S, Nutsuklo P, Nwachukwu CU, NWAFULUME NNAEMEKA, Nwangwu E, Nwankwo EP, Nyame CA, Nyamekye E, Nyankah E, Nyoka-Mokgalong C, Oase D, Obande JO, Obbeng A, Obeng-Adjei GI, Obianyo I, Obianyo NE, Obiechina S, OBRI AI, ODI TEMITOPE, Odingo J, Oelofsen S, Ofori E, Ofori-Adjei D, Ogaji IM, Ogundoyin OO, OGUNLEYE OLABISI, OGUNS A, Ogunsua O, Ohemeng-Mensah E, Ojediran O, Ojediran O, Ojewuyi A, Ojewuyi O, Ojo A, OJO OO, Ojo O, Okedare A, Okenwa SC, Oko AG, Okojie N, Okonkwo LN, Okoth P, Okunlola AI, Okunlola CK, Okurut M, Oladimeji M, Oladiran A, Olagunju GR, Olajide ARL, Olajide AT, Olang PR, Olayinka O, Olori S, Olulana D, Olulana DI, Olusanya B, Omar DE, Omar MA, Onakpoya U, ONeil M, Onen H, ONYEKA C, Oosthuizen A, Opandoh I, Opiyo S, Oppong J, Orewole TO, Orji M, Osagie O, Osagie OT, Osaheni O, Osama Sleem A, Osawa FO, Osei F, Osei-Nketiah S, Osei-Poku D, Osman A, Osman Ahmed M, Osman Suliman SO, Otchere K, Othman AAA, Othman E, Othman M, Otim P, Otim T, Otman RH, Otoki V, OUDJHIH M, OUEDRAOGO I, OUEDRAOGO PJ, Ousmane Hamady I, Ouyahia A, OWOJUYIGBE A, Owoo C, Owoo P, Owusu Boamah M, Oyedele A, Oyedepo O, Oyegbola C, Panday J, Parker EUE, Parker I, Parker RK, Pembe JN, Percivale B, Pereko J, Pérez M, Perumal N, Pillay L, Pretorius R, Prinsloo R, Pryce C, Puryag A, QUADRI OR, Quansah K, Quarcoopome C, Quarshie A, Quartson E, Quashie-Sam J, Rabiu A, Rabiu T, Rahma M, Rahman GA, Rais M, Rajah C, Rakotondrainibe A, Ramakrishnan R, Ramatou S, Ramdawon B, Ramdhani K, Ramkaun Y, RAPHAEL OSELE, Raslan HMA, Redelinghuys C, Riffi O, Rikhotso H, Roberts CAP, Robertson C, Roland N, Roos J, S. Abdalgadir E, Saad A, Saad MM, Saad El-Tanekhy A, Saadi C, Saadu T, Saber M, Sabir Yassin FM, Sabo VY, Sabra TA, Saeid DA, Safar A, Sagboze S, Sahnoun L, Salahu BM, Salami K, Salawu AI, Saleh H, Saleh IA, Saleh KM, Salele AM, Salem F, Salem O, Salih MAIA, Salisu I, Sall M, SAMB CF, Sangak IA, Sanoussi NM, Sanya D, Sanyang AB, Sarpong P, SARR JN, Schnaubelt R, Searyoh K, SECK NF, Secka AS, Seif M, Seilbea Y, Semret Hailu B, Sepenu P, Sewlall J, Seyi-Olajide J, Shai S, Shalaby AMO, SHAPHAT IBRAHIM, Shava G, Sheidu Owuda A, Sheshe AA, Shetiwy M, Shezi N, Shihab MH, Shitakumuna H, Shitaye N, Shitta AH, Sholadoye TT, Shouasha P, Shu'aibu NG, Shuiap NM, Sibeko B, Sikhakhane S, Sikwete G, Sime Gizaw H, Simelane N, Simon E, Singh U, SIRAJALDIN A, Siriboe E, Siyothula T, Siyotula T, Smart-Yeboah A, SMITH S, Solala S, Soliman EA, Solo CE, Sombéwendin Charles I, Sonaike M, Songden DZ, Sottie D, Soualili Z, Soula E, Souleymane S, SOWANDE OA, Spytko A, Srir DOM, Ssebuguzi L, Stegmann GF, Strauss L, Struwig E, Succi M, Suleiman AR, Suliman M, Swartz M, Taha TM, Takai IU, Takou BH, Takrouney MH, Takure A, TALABI AO, Tall M, Taute C, Tawfik M, Taylor J, Tembe DS, Temesgen F, Tesfaye E, Theko D, Thiart M, Thompson R, Thuer L, Tientcheu Fabrice T, Tilahun ZB, Tilahun Woldetsadik T, Timo M, Timotews N, Tjiyokola D, Tolani MA, TOUABTI S, Traoré D, Tsegha LJ, Tseli M, Tumuhimbise C, Tumukunde J, Tunkara SFS, Turshan L, Turton E, Uchendu CC, UDIE GU, UDOSEN JE, Ugalahi M, Ugwu EM, UGWU IE, Ugwu JO, Ugwunne CA, Ukpabio UE, Umar AM, UMEH CL, Ungen R, Usang U, Usenbo T, Usman MI, UWAYESU R, Van Aswegen B, van der Byl A, van der Linde P, van der Walt S, van Schalkwyk HP, van Tonder C, van Vuuren S, van Wyk J, van Zyl S, Wabule A, Wacays A, Waheed Mowafy G, Waisiko B, Walawah D, Walithandia E, Wamwaki J, Wataaka N, Wessels N, Wessels N, Williams E, WILLIAMS O, Woldegiorgis A, Wolfaardt G, Wondossen M, Woodun R, Workineh ST, Wubetu S, Yahia M, Yakubu H, Yakubu SY, Yalewu DZ, YAMEOGO TAC, Yeboah F, YENYI AHUKA LONGOMBE T, Younes E, Young C, Younis N, Younus TYI, YUSUF STEPHEN, Zaki F, Zbida I, Zenda T, ZERIZER Y, Zingoni K, Zitouni H, ZONGO PV, Zubi A, Zulu N, Zulu N, Yakubu H, Yakubu SY, Yalewu DZ, YAMEOGO TAC, Yeboah F, YENYI AHUKA LONGOMBE T, Younes E, Young C, Younis N, Younus TYI, YUSUF STEPHEN, Zaki F, Zbida I, Zenda T, ZERIZER Y, Zingoni K, Zitouni H, ZONGO PV, Zubi A, Zulu N, Zulu N. Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study. Lancet 2024; 403:1482-1492. [PMID: 38527482 DOI: 10.1016/s0140-6736(24)00103-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/09/2024] [Accepted: 01/18/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa. METHODS This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407. FINDINGS We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals). INTERPRETATION Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue. FUNDING Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.
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Faysal S, Penn-Kekana L, Day LT, Tripathi V, Khan F, Stafford R, Levin K, Campbell O, Filippi V. Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review. Int J Gynaecol Obstet 2024; 165:43-58. [PMID: 37698080 DOI: 10.1002/ijgo.15079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs). OBJECTIVES To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature. SEARCH STRATEGY The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS. SELECTION CRITERIA English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included. DATA COLLECTION AND ANALYSIS A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework. MAIN RESULTS Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels. CONCLUSIONS There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.
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Affiliation(s)
- Sumeya Faysal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Louise-Tina Day
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Farhad Khan
- EngenderHealth, Washington, District of Columbia, USA
| | | | - Karen Levin
- EngenderHealth, Washington, District of Columbia, USA
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Veronique Filippi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Diehl T, Jaraczewski TJ, Ahmed KS, Khan MR, Harrison EM, Abebe BM, Latif A, Mughal N, Khan S, McQueen KAK, Tefera G, Zafar SN. Barriers and Facilitators to Collecting Surgical Outcome Data in Low- and Middle-Income Countries: An International Survey. ANNALS OF SURGERY OPEN 2024; 5:e384. [PMID: 38883944 PMCID: PMC11175866 DOI: 10.1097/as9.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/08/2024] [Indexed: 06/18/2024] Open
Abstract
Background Perioperative data are essential to improve the safety of surgical care. However, surgical outcome research (SOR) from low- and middle-income countries (LMICs) is disproportionately sparse. We aimed to assess practices, barriers, facilitators, and perceptions influencing the collection and use of surgical outcome data (SOD) in LMICs. Methods An internet-based survey was developed and disseminated to stakeholders involved in the care of surgical patients in LMICs. The Performance of Routine Information Systems Management framework was used to explore the frequency and relative importance of organizational, technical, and behavioral barriers. Associations were determined using χ 2 and ANOVA analyses. Results Final analysis included 229 surgeons, anesthesia providers, nurses, and administrators from 36 separate LMICs. A total of 58.1% of individuals reported that their institution had experience with collection of SOD and 73% of these reported a positive impact on patient care. Mentorship and research training was available in <50% of respondent's institutions; however, those who had these were more likely to publish SOD (P = 0.02). Sixteen barriers met the threshold for significance of which the top 3 were the burden of clinical responsibility, research costs, and accuracy of medical documentation. The most frequently proposed solutions were the availability of an electronic data collection platform (95.3%), dedicated research personnel (93.2%), and access to research training (93.2%). Conclusions There are several barriers and facilitators to collection of SOD that are common across LMICs. Most of these can be addressed through targeted interventions and are highlighted in this study. We provide a path towards advancing SOR in LMICs.
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Affiliation(s)
- Thomas Diehl
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | | | - Kaleem Sohail Ahmed
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | | | - Ewen M Harrison
- Department of Clinical Surgery, The University of Edinburgh, Edinburgh, United Kingdom
| | - Belay Mellese Abebe
- Department of Surgery, Hawassa University Comprehensive Specialized Hospital, Awassa, Ethiopia
| | - Asad Latif
- Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - Nabiha Mughal
- Department of Surgical Oncology, Department of Surgery, New York University Medical Center, New York, NY
| | - Sadaf Khan
- Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - K A Kelly McQueen
- Department of Anesthesia, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Girma Tefera
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Syed Nabeel Zafar
- From the Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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Spijkerman S, Manning DM, Green-Thompson LP. Undergraduate Anesthesia Skills for a Global Surgery Agenda: Students' Self-Reported Competence. Anesth Analg 2024; 138:616-625. [PMID: 36888537 DOI: 10.1213/ane.0000000000006375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Safe anesthesia is imperative for the Global Surgery agenda and Sustainable Development Goal 3. Due to a shortage of specialists in South Africa (SA), anesthetic services are often provided by nonspecialist doctors, often newly qualified and frequently without immediate supervision. The burden of disease in the developing world demands fit-for-purpose, day-one medical graduates. Although undergraduate anesthesia training is mandatory for medical students in SA, no outcomes are specified, and these are decided autonomously at each medical school. This study describes the current self-perceived anesthetic competence of medical students in SA as a needs assessment directed at achieving the goals of Global Surgery in SA and other developing countries. METHODS In this cross-sectional observational study, 1689 students (89% participation rate), representing all medical schools in SA, rated their self-perceived competence at graduation in 54 anesthetic-related Likert scale items in 5 themes: patient evaluation, patient preparation for anesthesia, practical skills performance, administration of anesthesia, and the management of intraoperative complications. Medical schools were divided into clusters A (≥25 days of anesthetic training) and B (<25 days). Descriptive statistics, Fisher exact test, and a mixed-effects regression model were used in the statistical analysis. RESULTS Students felt more prepared for history-taking and patient examination than for managing emergencies and complications. The self-perceived competence of students at cluster A schools was higher across all 54 items and all 5 themes. The same was observed for general medical skills and skills relating to maternal mortality in SA. CONCLUSIONS Time-on-task, capacity for repetition, and student maturity might have impacted self-efficacy and should be considered in curriculum development. Students felt less prepared for emergencies. Focused training and assessment aimed at emergency management should be considered. Students did not feel competent in general medical areas, in which anesthetists are experts, including resuscitation, fluid management, and analgesia. Anesthetists should take ownership of this training at the undergraduate level. Cesarean delivery is the most performed surgical procedure in sub-Saharan Africa. The Essential Steps in Managing Obstetric Emergencies (ESMOE) program was designed for internship training but can be introduced at undergraduate level. This study suggests that curriculum reform is required. The achievement of an agreed-upon set of standardized national undergraduate anesthetic competencies may ensure fit-for-purpose practitioners. Undergraduate and internship training should align to form part of a continuum of basic anesthetics training in SA. The findings of this study might benefit curriculum development in other regions with similar contexts.
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Otoki K, Parker AS, Many HR, Parker RK. Gender Disparities in Complications, Costs, and Mortality After Emergency Gastrointestinal Surgery in Kenya. J Surg Res 2024; 295:846-852. [PMID: 37543494 DOI: 10.1016/j.jss.2023.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Little is known about the impact of gender on emergency surgery within Kenya. Therefore, we aimed to investigate the association of gender on outcomes of postoperative complications, health care costs, and mortality. METHODS We evaluated an established cohort of patients undergoing emergency gastrointestinal surgery in rural Kenya between January 1st, 2016 and June 30th, 2019. Utilizing logistic regression, we examined the association between self-reported patient gender and the outcomes of postoperative complications and mortality. A generalized linear model was created for total hospital costs, inflation-adjusted in international dollars purchasing power parity, to examine the impact of gender. Confounding factors were controlled by Africa Surgical Outcomes Study Surgical Risk Score. RESULTS Among 484 patients reviewed, 149 (30.8%) were women. 165 (34.1%) patients developed complications, with women experiencing more than men (40.9% versus 31.0%; P = 0.03) and longer hospital stays (median 6 days (4-9) versus 5 (4-7); P = 0.02). After controlling for Africa Surgical Outcomes Study Surgical Risk Score, odds of developing complications for women were 1.67 (95% confidence interval: 1.09-2.55; P = 0.019) times higher than men, and the odds of death were 2.38 (95% confidence interval: 1.12-5.09; P = 0.025) times greater for women than men, despite similar failure-to-rescue rates and intensive care unit utilization. Total hospital costs were increased for women by 531 international dollars purchasing power parity (117-946; P = 0.012) when compared to men, attributed to longer lengths of stay. CONCLUSIONS These findings demonstrate that a discrepancy exists between men and women undergoing emergency gastrointestinal surgery in our setting. Further exploration of the underlying causes of this inequity is necessary for quality improvement for women in rural Kenya.
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Affiliation(s)
- Kemunto Otoki
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/kemuntootoki
| | - Andrea S Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/AP_the_surgeon
| | - Heath R Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
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Starr N, Gebeyehu N, Nofal MR, Forrester JA, Tesfaye A, Mammo TN, Weiser TG. Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments. JAMA Surg 2024; 159:161-169. [PMID: 38019510 PMCID: PMC10687710 DOI: 10.1001/jamasurg.2023.6033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/07/2023] [Indexed: 11/30/2023]
Abstract
Importance Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support. Objective To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined. Design, Setting, and Participants This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls. Exposure Implementation of the refined Clean Cut program. Main Outcomes and Measures The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications. Results A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly. Conclusions and Relevance A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.
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Affiliation(s)
- Nichole Starr
- Department of Surgery, University of California, San Francisco
- Lifebox Foundation, New York, New York
| | - Natnael Gebeyehu
- Lifebox Foundation, New York, New York
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maia R. Nofal
- Lifebox Foundation, New York, New York
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - Assefa Tesfaye
- Lifebox Foundation, New York, New York
- Department of Surgery, St Peter’s Specialized Hospital, Addis Ababa, Ethiopia
| | - Tihitena Negussie Mammo
- Lifebox Foundation, New York, New York
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Thomas G. Weiser
- Lifebox Foundation, New York, New York
- Department of Surgery, Stanford University, Palo Alto, California
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Ndong A, Togtoga L, Bah MS, Ndoye PD, Niang K. Prevalence and mortality rate of abdominal surgical emergencies in Sub-Saharan Africa: a systematic review and meta-analysis. BMC Surg 2024; 24:35. [PMID: 38267892 PMCID: PMC10809467 DOI: 10.1186/s12893-024-02319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/10/2024] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Abdominal surgical emergencies remain prevalent in various healthcare settings, particularly in regions with limited access to basic surgical care, such as Africa. The aim of this literature review is to systematically assess publications on abdominal surgical emergencies in adults in sub-Saharan Africa to estimate their prevalence and mortality rate. METHODOLOGY A systematic review was conducted. The latest search was performed on October 31, 2022. We estimated the pooled prevalence with a 95% confidence interval (CI) for each abdominal surgical emergency, as well as overall postoperative mortality and morbidity rates. RESULTS A total of 78 studies were included, and 55.1% were single-center retrospective and monocentric studies. The mean age of the patients was 32.5 years, with a sex ratio of 1.94. The prevalence of each abdominal surgical emergency among all of them was as follows: appendicitis: 30.0% (95% CI: 26.1-33.9); bowel obstruction: 28.6% (95% CI: 25.3-31.8); peritonitis: 26.6% (95% CI: 22.2-30.9); strangulated hernias: 13,4% (95% CI: 10,3-16,5) and abdominal trauma: 9.4% (95% CI: 7.5-11.3). The prevalence of complications was as follows: mortality rate: 7.4% (95% CI: 6.0-8.8); overall postoperative morbidity: 24.2% (95% CI: 19.4-29.0); and surgical site infection 14.4% (95% CI: 10.86-18.06). CONCLUSION Our study revealed a high prevalence of postoperative complications associated with abdominal surgical emergencies in sub-Saharan Africa. More research and efforts should be made to improve access and quality of patient care.
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Affiliation(s)
- Abdourahmane Ndong
- Department of Public Health and Social Medicine, Faculty of Health Sciences, Gaston Berger University, Saint-Louis, Senegal.
- General Surgery Department, Regional Hospital Center of Saint Saint-Louis, Saint-Louis, Senegal.
| | - Lebem Togtoga
- Department of Public Health and Social Medicine, Faculty of Health Sciences, Gaston Berger University, Saint-Louis, Senegal
| | - Mamadou Saïdou Bah
- Department of Public Health and Social Medicine, Faculty of Health Sciences, Gaston Berger University, Saint-Louis, Senegal
| | - Papa Djibril Ndoye
- Department of Public Health and Social Medicine, Faculty of Health Sciences, Gaston Berger University, Saint-Louis, Senegal
| | - Khadim Niang
- Department of Public Health and Social Medicine, Faculty of Health Sciences, Gaston Berger University, Saint-Louis, Senegal
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Ranganathan P, Dare A, Harrison EM, Kingham TP, Mutebi M, Parham G, Sullivan R, Pramesh CS. Inequities in global cancer surgery: Challenges and solutions. J Surg Oncol 2024; 129:150-158. [PMID: 38073139 PMCID: PMC11186466 DOI: 10.1002/jso.27551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023]
Abstract
The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.
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Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anna Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Groesbeck Parham
- Department of Obstetrics and Gynecology, Charles Drew University of Science and Medicine, Los Angeles, California, USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Richard Sullivan
- School of Cancer Sciences, Centre for Cancer Society and Public Health, Institute of Cancer Policy, King’s College London, London, UK
| | - C. S. Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Wiedermann J, Douse DM, Green KJ, Pang JC, Blount Q, Yu K, Shrime M. Outcomes of Short-Term Surgical Trips in Otolaryngology-Head and Neck Surgery: A Scoping Review. Laryngoscope 2024; 134:32-39. [PMID: 37249184 DOI: 10.1002/lary.30764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/25/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE This scoping review aims to explore the current body of literature to characterize how short-term surgical trips (STSTs) in Otolaryngology-Head and Neck Surgery (OtoHNS) contribute to surgical, educational, and sustainability-based outcomes in low- and middle-income countries (LMICs). We aim to use these data to synthesize aspects of STSTs that are successful with the hopes of shaping future global efforts. DATA SOURCES Data sources included Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. REVIEW METHODS A comprehensive search was conducted on several databases from inception to October 14, 2021. We included primary studies exploring any surgical or educational outcomes of global short-term surgical endeavors within LMICs. Data were then extracted to evaluate the heterogenous body of literature that exists, characterizing the surgical, educational, and sustainability-based outcomes. RESULTS Forty-Seven studies were included in the final analysis. Most publications were focused on surgical interventions (39 of 47; 82.9%); 13 (27.7%) studies included education as the primary aim and 12 (25.5%) considered sustainability a significant aim. Of the 94 first and last authors, there were zero first authors and only one last author with an LMIC affiliation. Twenty-six studies (55%) mentioned that any patients were seen in follow-up, ranging from one day to five years. CONCLUSION Our scoping review demonstrates that most STSTs have focused primarily on surgical procedures with a lack of appropriate long-term follow-up. However, the available outcome-based information presented helps identify factors that characterize a strong short-term global surgical program. LEVEL OF EVIDENCE NA Laryngoscope, 134:32-39, 2024.
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Affiliation(s)
- Josh Wiedermann
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dontre' M Douse
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katerina J Green
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
- Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | | | - Karina Yu
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Mark Shrime
- Mercy Ships, Garden Valley, Texas, USA
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
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Nourian MM, Alshibli A, Kamau J, Nabulindo S, Amollo DA, Connell J, Eden SK, Seyoum R, Teklehaimanot MG, Tegu GA, Desta HB, Newton M, Sileshi B. Capnography access and use in Kenya and Ethiopia. Can J Anaesth 2024; 71:95-106. [PMID: 37914969 DOI: 10.1007/s12630-023-02607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Lack of access to safe and affordable anesthesia and monitoring equipment may contribute to higher rates of morbidity and mortality in low- and middle-income countries (LMICs). While capnography is standard in high-income countries, use in LMICs is not well studied. We evaluated the association of capnography use with patient and procedure-related characteristics, as well as the association of capnography use and mortality in a cohort of patients from Kenya and Ethiopia. METHODS For this retrospective observational study, we used historical cohort data from Kenya and Ethiopia from 2014 to 2020. Logistic regression was used to study the association of capnography use (primary outcome) with patient/procedure factors, and the adjusted association of intraoperative, 24-hr, and seven-day mortality (secondary outcomes) with capnography use. RESULTS A total of 61,792 anesthetic cases were included in this study. Tertiary or secondary hospital type (compared with primary) was strongly associated with use of capnography (odds ratio [OR], 6.27; 95% confidence interval [CI], 5.67 to 6.93 and OR, 6.88; 95% CI, 6.40 to 7.40, respectively), as was general (vs regional) anesthesia (OR, 4.83; 95% CI, 4.41 to 5.28). Capnography use was significantly associated with lower odds of intraoperative mortality in patients who underwent general anesthesia (OR, 0.31; 95% CI, 0.17 to 0.48). Nevertheless, fully-adjusted models for 24-hr and seven-day mortality showed no evidence of association with capnography. CONCLUSION Capnography use in LMICs is substantially lower compared with other standard anesthesia monitors. Capnography was used at higher rates in tertiary centres and with patients undergoing general anesthesia. While this study revealed decreased odds of intraoperative mortality with capnography use, further studies need to confirm these findings.
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Affiliation(s)
- Maziar M Nourian
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Amany Alshibli
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - John Kamau
- African Mission Healthcare, ImPACT Africa-Tanzania, Nairobi, Kenya
| | - Susan Nabulindo
- Department of Anesthesiology, University of Nairobi, Nairobi, Kenya
| | - Dennis A Amollo
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahel Seyoum
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Gebrehiwot A Tegu
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Haftom B Desta
- Department of Anesthesiology, Mekelle University, Mekelle, Ethiopia
| | - Mark Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bantayehu Sileshi
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Mohamed SS, Temu R, Komba LF, Kaino MM, Olotu FI, Ndebea AS, Vaughan BN. Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study. Anesth Analg 2024; 138:180-186. [PMID: 36727852 DOI: 10.1213/ane.0000000000006374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania. METHODS Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively. RESULTS A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87-95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4-8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93-98) patients and 145 of 170 (95% CI, 80-90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed. CONCLUSIONS Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.
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Affiliation(s)
| | - Rogers Temu
- Department of Orthopedics and Traumatology, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Leticia F Komba
- Department of Anesthesiology, Mbeya Zonal Referral Hospital, Mbeya, Tanzania
| | - Mwemezi M Kaino
- Department of Anesthesiology, AIC CURE International Hospital, Kijabe, Kenya
| | - Frank I Olotu
- Department of Physiotherapy, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Ansbert S Ndebea
- Department of Anesthesiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brian N Vaughan
- Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio
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Wagstaff D, Shenouda J. Perioperative medicine: challenges and solutions for global health. Br J Hosp Med (Lond) 2023; 84:1-8. [PMID: 38153020 DOI: 10.12968/hmed.2023.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The emerging field of perioperative medicine has the potential to make significant contributions to global health. Perioperative medicine aims to help reduce unmet surgical need, decrease variation in quality and systematically improve patient outcomes. These aims are also applicable to key challenges in global health, such as limited access to surgical care, variable quality and workforce shortages. This article describes the areas in which perioperative medicine can contribute to global health using case studies of successful care pathways, risk prediction tools, strategies for effective grassroots research and novel workforce approaches aimed at effectively using limited resources.
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Affiliation(s)
- Duncan Wagstaff
- Centre for Perioperative Medicine, Division of Surgery and Targeted Intervention, University College London, London, UK
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Are C, Murthy SS, Sullivan R, Schissel M, Chowdhury S, Alatise O, Anaya D, Are M, Balch C, Bartlett D, Brennan M, Cairncross L, Clark M, Deo SVS, Dudeja V, D'Ugo D, Fadhil I, Giuliano A, Gopal S, Gutnik L, Ilbawi A, Jani P, Kingham TP, Lorenzon L, Leiphrakpam P, Leon A, Martinez-Said H, McMasters K, Meltzer DO, Mutebi M, Zafar SN, Naik V, Newman L, Oliveira AF, Park DJ, Pramesh CS, Rao S, Subramanyeshwar Rao T, Bargallo-Rocha E, Romanoff A, Rositch AF, Rubio IT, Salvador de Castro Ribeiro H, Sbaity E, Senthil M, Smith L, Toi M, Turaga K, Yanala U, Yip CH, Zaghloul A, Anderson BO. Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide. Lancet Oncol 2023; 24:e472-e518. [PMID: 37924819 DOI: 10.1016/s1470-2045(23)00412-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 11/06/2023]
Abstract
The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.
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Affiliation(s)
- Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Shilpa S Murthy
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, King's College London, London, UK
| | - Makayla Schissel
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sanjib Chowdhury
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Olesegun Alatise
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Daniel Anaya
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Madhuri Are
- Division of Pain Medicine, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Charles Balch
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, Global Cancer Surgery: pragmatic solutions to improve USA
| | - David Bartlett
- Department of Surgery, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Murray Brennan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lydia Cairncross
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Matthew Clark
- University of Auckland School of Medicine, Auckland, New Zealand
| | - S V S Deo
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Dudeja
- Division of Surgical Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Domenico D'Ugo
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | - Armando Giuliano
- Cedars-Sinai Medical Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Washington DC, USA
| | - Lily Gutnik
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andre Ilbawi
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Pankaj Jani
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | | | - Laura Lorenzon
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Premila Leiphrakpam
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Augusto Leon
- Department of Surgical Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Kelly McMasters
- Division of Surgical Oncology, Hiram C Polk, Jr MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - David O Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Syed Nabeel Zafar
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Vibhavari Naik
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | - Lisa Newman
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | | | - Do Joong Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Saieesh Rao
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - T Subramanyeshwar Rao
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | | | - Anya Romanoff
- Department of Global Health and Health System Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | | | - Eman Sbaity
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Maheswari Senthil
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, Irvine, CA, USA
| | - Lynette Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Masakazi Toi
- Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Japan
| | - Kiran Turaga
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ujwal Yanala
- Surgical Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Cheng-Har Yip
- Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
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Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study. Int J Surg 2023; 109:3954-3966. [PMID: 38258997 PMCID: PMC10720814 DOI: 10.1097/js9.0000000000000711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. METHODS LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January-December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien-Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). RESULTS A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. CONCLUSIONS This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives.
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Zhang J, Wu N, Li M. A prediction model for cesarean delivery based on the glycemia in the second trimester: a nested case control study from two centers. J Matern Fetal Neonatal Med 2023; 36:2222208. [PMID: 37332139 DOI: 10.1080/14767058.2023.2222208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 12/20/2022] [Accepted: 06/01/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Maternal glycemia is associated with the risk of cesarean delivery (CD); therefore, our study aims to developed a prediction model based on glucose indicators in the second trimester to earlier identify the risk of CD. METHODS This was a nested case-control study, and data were collected from the 5th Central Hospital of Tianjin (training set) and Changzhou Second People's Hospital (testing set) from 2020 to 2021. Variables with significant difference in training set were incorporated to develop the random forest model. Model performance was assessed by calculating the area under the curve (AUC) and Komogorov-Smirnoff (KS), as well as accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS A total of 504 eligible women were enrolled; of these, 169 underwent CD. Pre-pregnancy body mass index (BMI), first pregnancy, history of full-term birth, history of livebirth, 1 h plasma glucose (1hPG), glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2 h plasma glucose (2hPG) were used to develop the model. The model showed a good performance, with an AUC of 0.852 [95% confidence interval (CI): 0.809-0.895]. The pre-pregnancy BMI, 1hPG, 2hPG, HbA1c, and FPG were identifies as the more significant predictors. External validation confirmed the good performance of our model, with an AUC of 0.734 (95%CI: 0.664-0.804). CONCLUSIONS Our model based on glucose indicators in the second trimester performed well to predict the risk of CD, which may reach the earlier identification of CD risk and may be beneficial to make interventions in time to decrease the risk of CD.
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Affiliation(s)
- Junping Zhang
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Naiqian Wu
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Minhui Li
- Department of Obstetrics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, P.R. China
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Powell WF, Echeto-Cerrato MA, Gathuya Z, Gray RM, Hodges S, Nabukenya MT, Newton MW, Rai E, Evans FM. Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries. World J Surg 2023; 47:3429-3435. [PMID: 37891383 DOI: 10.1007/s00268-023-07229-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.
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Affiliation(s)
- William Francis Powell
- Department of Anesthesiology, Harvard Medical School, Mass Eye and Ear243 Charles Street, Boston, MA, 02114, USA.
| | - Maria Alejandra Echeto-Cerrato
- Department of Anesthesiology and Pediatrics, Hospital del Valle North Blvd, 8Th Street NE, San Pedro Sula, Honduras, 21101
| | | | - Rebecca Mary Gray
- Division of Paediatric Anaesthesia, Division of Global Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, 27 St Michaels Rd, Tamboerskloof, Cape Town, 8001, Republic of South Africa
| | | | - Mary T Nabukenya
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Upper Mulago Hill Rd, Kampala, Uganda
| | - Mark W Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ekta Rai
- Department of Anaesthesiology, Christian Medical College, Vellore, India, 632004
| | - Faye M Evans
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
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Birgand G, Dhar P, Holmes A. The threat of antimicrobial resistance in surgical care: the surgeon's role and ownership of antimicrobial stewardship. Br J Surg 2023; 110:1567-1569. [PMID: 37758500 PMCID: PMC10638523 DOI: 10.1093/bjs/znad302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Gabriel Birgand
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Regional Center for Infection Prevention and Control, Region of Pays de la Loire, Nantes University Hospital, Nantes, France
- Cibles et médicaments des infections et de l'immunité, IICiMed, UR 1155, Nantes Université, Nantes, France
| | - Puneet Dhar
- Surgical Gastroenterology, Amrita Hospital, Faridabad, India
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Faculty of Health Sciences, University of Liverpool, Liverpool, UK
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Kalisya LM, Yap A, Mitume B, Salmon C, Karafuli K, Poenaru D, Onyango R. Determinants of Access to Essential Surgery in the Democratic Republic of Congo. J Surg Res 2023; 291:480-487. [PMID: 37536189 DOI: 10.1016/j.jss.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access. METHODS A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed. RESULTS Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care. CONCLUSIONS Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.
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Affiliation(s)
- Luc Malemo Kalisya
- Department of Community Health and Development, Great Lakes University of Kisumu, Kisumu, Kenya
| | - Ava Yap
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, California.
| | - Boniface Mitume
- Department of Computer Engineering, Université Officielle de Ruwenzori, Butembo, DRC
| | - Christian Salmon
- Center for Global Health Engineering, Department of Engineering Management and Industrial Engineering, Western New England University, Springfield, Massachusetts
| | | | - Dan Poenaru
- Department of Pediatric Surgery, McGill University, Montreal, Quebec, Canada
| | - Rosebella Onyango
- Department of Community Health and Development, Great Lakes University of Kisumu, Kisumu, Kenya
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Crawford AM. Short courses fall short of health system strengthening. Anaesthesia 2023; 78:1323-1326. [PMID: 37527548 DOI: 10.1111/anae.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/03/2023]
Affiliation(s)
- A M Crawford
- Department of Anaesthesiology, Peri-operative and and Pain Management, Stanford University, Stanford, CA, USA
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Wollner EA, Nourian MM, Bertille KK, Wake PB, Lipnick MS, Whitaker DK. Capnography-An Essential Monitor, Everywhere: A Narrative Review. Anesth Analg 2023; 137:934-942. [PMID: 37862392 DOI: 10.1213/ane.0000000000006689] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography's use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography's use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography's safety benefits to all patients, everywhere.
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Affiliation(s)
- Elliot A Wollner
- From the Department of Anaesthesia and Perioperative Medicine, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
- Center for Health Equity in Surgery and Anesthesia (CHESA), University of California, San Francisco, California
| | - Maziar M Nourian
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ki K Bertille
- Centre Hospitalier Universitaire Pédiatrique Charles de Gaulle, Ouagadougou, Burkina Faso
| | - Pauline B Wake
- School of Medicine and Health Sciences, University of Papua New Guinea
| | - Michael S Lipnick
- Department of Anesthesia and Perioperative Medicine, Center for Health Equity in Surgery and Anesthesia (CHESA), University of California, San Francisco, California
| | - David K Whitaker
- Department of Anaesthesia and Intensive Care, Manchester Royal Infirmary, United Kingdom
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English M, Oliwa J, Khalid K, Onyango O, Willows TM, Mazhar R, Mkumbo E, Guinness L, Schell CO, Baker T, McKnight J. Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic. BMJ Glob Health 2023; 8:e013407. [PMID: 37918869 PMCID: PMC10626868 DOI: 10.1136/bmjgh-2023-013407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023] Open
Abstract
Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Onesmus Onyango
- KEMRI-Wellcome Trust Research Programme, Health Services Unit, Nairobi, Kenya
| | - Tamara Mulenga Willows
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rosanna Mazhar
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, London, UK
- Centre for Global Development, London, UK
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Karolinska Institute, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Stahlschmidt A, Passos SC, Dornelles DD, Polanczyk C, Gutierrez CS, Minuzzi RR, Castro SMJ, Stefani LC. Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance. Can J Anaesth 2023; 70:1776-1788. [PMID: 37853279 DOI: 10.1007/s12630-023-02558-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/02/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
PURPOSE Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
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Affiliation(s)
- Adriene Stahlschmidt
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Sávio C Passos
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Debora D Dornelles
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Polanczyk
- Cardiology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Claudia S Gutierrez
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rosangela R Minuzzi
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
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Bishop D, van Dyk D, Dyer R. Safe obstetric anaesthesia in low- and middle-income countries-a perspective from Africa. BJA Educ 2023; 23:432-439. [PMID: 37876763 PMCID: PMC10591126 DOI: 10.1016/j.bjae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
- D. Bishop
- University of Kwazulu-Natal, Durban, South Africa
| | - D. van Dyk
- University of Cape Town, Cape Town, South Africa
| | - R.A. Dyer
- University of Cape Town, Cape Town, South Africa
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Mughal NA, Hussain MH, Ahmed KS, Waheed MT, Munir MM, Diehl TM, Zafar SN. Barriers to Surgical Outcomes Research in Low- and Middle-Income Countries: A Scoping Review. J Surg Res 2023; 290:188-196. [PMID: 37269802 DOI: 10.1016/j.jss.2023.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/30/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Systematic collection and analysis of surgical outcomes data is a cornerstone of surgical quality improvement. Unfortunately, there remains a dearth of surgical outcomes data from low- and middle-income countries (LMICs). To improve surgical outcomes in LMICs, it is essential to have the ability to collect, analyze, and report risk-adjusted postoperative morbidity and mortality data. This study aimed to review the barriers and challenges to developing perioperative registries in LMIC settings. METHODS We conducted a scoping review of all published literature on barriers to conducting surgical outcomes research in LMICs using PubMed, Embase, Scopus, and GoogleScholar. Keywords included 'surgery', 'outcomes research', 'registries', 'barriers', and synonymous Medical Subject Headings derivatives. Articles found were subsequently reference-mined. All relevant original research and reviews published between 2000 and 2021 were included. The performance of routine information system management framework was used to organize identified barriers into technical, organizational, or behavioral factors. RESULTS Twelve articles were identified in our search. Ten articles focused specifically on the creation, success, and obstacles faced during the implementation of trauma registries. Technical factors reported by 50% of the articles included limited access to a digital platform for data entry, lack of standardization of forms, and complexity of said forms. 91.7% articles mentioned organizational factors, including the availability of resources, financial constraints, human resources, and lack of consistent electricity. Behavioral factors highlighted by 66.6% of the studies included lack of team commitment, job constraints, and clinical burden, which contributed to poor compliance and dwindling data collection over time. CONCLUSIONS There is a paucity of published literature on barriers to developing and maintaining perioperative registries in LMICs. There is an immediate need to study and understand barriers and facilitators to the continuous collection of surgical outcomes in LMICs.
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Affiliation(s)
- Nabiha Akhlaq Mughal
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Muzamil Hamid Hussain
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | | | - Muhammad Talha Waheed
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan; Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Muhammad Musaab Munir
- Department of Surgery, Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Thomas M Diehl
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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47
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Degu S, Kejela S, Zeleke HT. Perioperative mortality of emergency and elective surgical patients in a low-income country: a single institution experience. Perioper Med (Lond) 2023; 12:49. [PMID: 37715264 PMCID: PMC10504717 DOI: 10.1186/s13741-023-00341-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The perioperative mortality rate is an indicator of access to safe anesthesia and surgery. Studies showed higher perioperative mortality rates among low- and middle-income countries. But the specific causes and factors contributing to perioperative death have not been adequately studied in the Ethiopian context. METHODS This is a retrospective institutional study of the largest academic medical center in Ethiopia. Data of all patients who were admitted to surgical wards or intensive care and underwent surgical interventions were evaluated for perioperative mortality rate determination. All mortality cases were then evaluated in depth. RESULTS Of the 3295 patients evaluated, a total of 148 patients (4.5%) died within 30 days of surgery. By the 7th postoperative day, 69.5% of the perioperative mortality had already occurred. Septic shock contributed to 54.2% of deaths. Emergency surgery patients had more than a twofold higher mortality rate than elective surgery patients (p value < 0.001) and had a 2.6-fold higher rate of dying within 7 days of surgery (p value of 0.02). Patients with ASA performance status of 3 or more had a 1.7-fold higher rate of death within 72 h of surgery (p value of 0.015). CONCLUSION More than two thirds of patients died within 7 postoperative days. More emergency patients died than elective counterparts, and emergency cases had a higher rate of dying within 7 days of surgery. Poor ASA performance score was associated with earlier postoperative death. Further prospective multi-institutional studies are warranted to elucidate the factors that contribute to higher postoperative mortality in low-income country patients.
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Affiliation(s)
- Samrawit Degu
- Department of Surgery, Lancet Biherawi General Hospital, Addis Ababa, Ethiopia
| | - Segni Kejela
- Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Biccard BM, Smith D, Peters S, Boutall A, Wilson G, Coetzee E, Flint M, Gumede S, Rayamajhi S, Bannister S, Daniel N, Fourtounas M, Moore R, Sentholang N, Osayomwanbo O, Ifeanyi kene A, Yakubu SY, Chukwu A, Tolani M, Adinoyi YM, Aliyu A, Salahu D, Isa kabir, Salisu I, Adigun T, Adenekan A, Williams E, Bhatia PK, Chaudhary R, Kothari N, Misra S, Pareek P, Poonia DR, Rathod KK, Rodha MS, Sharma N, Sharma N, Chandra Soni S, Varshney VK, Vishnoi JR, Balija SS, Goyal A, Hudda F, Joshva M, Seenivasagam RK, Shajahan S, Sharma S, Singh SK, Talwar P, Tripathi DK, Bhatt, Daniel S, Dhiman J, George C, Ghosh DN, Goyal S, Hans P, Haque PD, Jain D, Kaur H, Kumar K, Mahajan A, Michael V, Rajappa R, Rajkumar A, Suroy A, Thind RS, Veetil SK, Aggarwal AM, Dhamija P, Garry GK, Gupta H, Jakhar R, Kumar A, Kumar K, Kumar P, Singh G, Chowdhury S, Desai N, Goswami J, Mathai S, Patro V. Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries. BJA OPEN 2023; 7:100207. [PMID: 37655933 PMCID: PMC10457493 DOI: 10.1016/j.bjao.2023.100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 09/02/2023]
Abstract
Background This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was $216 compared with $222 for low FiO2 leading to a -$6 (95% confidence interval [CI]: -$13 to -$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with $195 for low FiO2 leading to a -$11 (95% CI: -$15 to -$6) difference in costs. In South Africa, the average cost for high FiO2 was $1164 compared with $1257 for low FiO2 leading to a -$93 (95% CI: -$132 to -$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a -1.05 (95% CI: -1.14 to -0.90) percentage point reduction in SSIs. Conclusion High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this.
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Parker RK, Otoki K, Sylvester K, Roberts L, Many HR, Kim GJ, Mwachiro MM, Parker AS. Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery. Surgery 2023; 174:324-329. [PMID: 37263881 DOI: 10.1016/j.surg.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/25/2023] [Accepted: 04/27/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes. METHODS We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses. RESULTS After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant. CONCLUSION Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.
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Affiliation(s)
| | - Kemunto Otoki
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/kemuntootoki
| | | | - Luke Roberts
- Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | - Heath R Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Grace J Kim
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/3amazinggrace
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/MichaelMwachiro
| | - Andrea S Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/AP_the_surgeon
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50
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Fitzgerald L, Tibyehabwa L, Varallo J, Ernest E, Patted A, Bertram MM, Alidina S, Mshana S, Katoto A, Simba D, Charles K, Smith V, Cainer M, Hellar A. Mentoring approaches in a safe surgery program in Tanzania: Lessons learned during COVID-19 and recommendations for the future. Surg Open Sci 2023; 14:109-113. [PMID: 37577254 PMCID: PMC10413135 DOI: 10.1016/j.sopen.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Background COVID-19 has dramatically affected the delivery of health care and technical assistance. This is true in Tanzania, where maternal mortality and surgical infection rates are significantly higher than in high-income countries. This paper describes lessons learned about the optimal application of in-person and virtual mentorship in the Safe Surgery 2020 program to improve the quality of surgical services in Tanzania before and after the COVID-19 pandemic. Methods From January 2018 through December 2020, Safe Surgery 2020 supported 40 health facilities in Tanzania's Lake Zone to improve the quality of surgical care. A blended surgical mentorship model, employing both onsite and virtual mentorship, was central to the program's capacity development approach. With COVID-19, the program pivoted to full virtual mentorship. Through continuous learning and adaptation processes, including a human-centered design workshop, surveys assessing mentors' confidence with different competencies, and focus group discussions with mentors, mentees and safe surgery program staff, the program distilled the optimal use of mentorship models. Results Developing complex surgical skills, addressing contextual considerations, problem-solving, and building trusting relationships were best suited to in-person mentorship, whereas virtual mentorship was most effective in supporting mentees' quality improvement projects, data use, case discussions, and reinforcing clinical practices. Leading successful virtual learning required enhanced facilitation skills and active engagement of health facility leadership. Conclusions In-person and virtual mentorship offer distinct benefits and complement each other when combined. Investing more in-person mentorship at the beginning of programs allows for the establishment of trust that is foundational to effective mentorship.
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Affiliation(s)
| | | | - John Varallo
- Jhpiego, 1615 Thames St, Baltimore, MD, United States
| | - Edwin Ernest
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
| | - Anmol Patted
- Jhpiego, 1615 Thames St, Baltimore, MD, United States
| | | | - Shehnaz Alidina
- Harvard T. H. Chan School of Public Health, Boston, MA, United States1
Current affiliation. - Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States2
Former affiliation.
| | - Stella Mshana
- Safe Surgery 2020 Project, Jhpiego Tanzania, Mara, Tanzania
| | - Adam Katoto
- Safe Surgery 2020 Project, Jhpiego Tanzania, Kagera, Tanzania
| | - Dorcas Simba
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
| | | | | | | | - Augustino Hellar
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
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