First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND

Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers.

AIM

To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery.

RESULTS

Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors.

CONCLUSION

Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.

Resolution of gastric antral vascular ectasia following cessation of imatinib

A female patient in her 80s presented with chronic iron-deficiency anaemia secondary to gastric antral vascular ectasia (GAVE), despite repeated endoscopic treatment. Her medical history was notable for chronic myeloid leukaemia, for which she took imatinib. Due to a possible association between imatinib and GAVE described in a small number of case reports, cessation of imatinib was trialled. This led to a significant improvement in the patient's anaemia and resolution of GAVE on repeat endoscopy. GAVE is an uncommon cause of gastrointestinal bleeding, the aetiology of which is uncertain. This report describes an approach to the differential diagnosis of chronic iron-deficiency anaemia and an overview of GAVE syndrome. It illustrates the benefit of broadening the differential when the diagnosis is uncertain and the utility of case reports in informing the differential diagnosis.

Sweet syndrome following the ChAdOx1-S vaccine

We report a case of vaccine-induced Sweet syndrome in a female patient in her 50s presenting with fevers and a scattered red patchy rash on the lower limbs. Seven days prior, she had received the first dose of AstraZeneca ChAdOx1-S vaccine. A skin biopsy confirmed Sweet syndrome. She did not respond to high doses of prednisolone and required methotrexate therapy to induce remission. This is one of the first reports of Sweet syndrome caused by the ChAdOx1-S vaccine and provides further evidence for vaccine-induced dermatosis. This case demonstrates that methotrexate can induce remission in cases of Sweet syndrome resistant to corticosteroids. This report also describes an approach to the differential diagnosis of patients presenting with a rash, fever and malaise.

Examination of a Nurse Anesthesia Program's Teaching Assistant Model and Its Impact on Increasing Nurse Anesthesia Education Capacity

A nurse anesthesia educator shortage exists that is attributed to factors such as a lack of financial incentive and proper training to be an educator. Due to the faculty shortage, nurse anesthesia programs (NAPs) are forced to defer admission to qualified applicants which reduces the number of certified registered nurse anesthetists (CRNAs) that NAPs can produce. Research regarding students as teaching assistants (TAs) at the university level has shown benefits and challenges to students, professors, and the TAs themselves as well as the impact on the overall faculty capacity. Current research regarding TA programs does not pertain to NAPs, therefore, research regarding the impact of TA programs on increasing nurse anesthesia faculty merits further work. This study was conducted using quantitative surveys and qualitative interviews to bridge the gap in the literature on the potential impact of TA programs on NAP faculty shortages. A survey was sent via email to former TAs (n = 44) of the Georgetown University NAP to assess the impact that the TA program had on their decision to enter a role in academia after graduation. Interviews were then conducted on a voluntary basis via a video conferencing platform to add qualitative data to the survey results. The survey response rate was 45% (n = 20). Following proportional analysis, 80% of the survey respondents indicated that they participated in the education of student registered nurse anesthetists in the clinical or didactic setting as a CRNA. Eighty percent of respondents indicated that being a TA positively influenced their desire to become a faculty member. One hundred percent of CRNAs interviewed reported that the biggest barrier to becoming fulltime faculty was the lack of financial incentives offered by NAPs. Interviewees recalled their TA experience as the foundation for their enjoyment of teaching anesthesia. The results of this study indicate that TA programs in NAPs can be used as a method to increase faculty capacity.

Experience delivering an integrated service model to people with criminal justice system involvement and housing insecurity

BACKGROUND

People returning to communities from prison or jail face stressors related to securing housing, including discrimination, restrictions based on prior felony convictions, and limited economic and social resources. Existing housing programs can effectively reduce housing instability but often do not fully address the needs of people involved in the criminal justice system experiencing homelessness who often have co-occurring chronic medical issues, and psychiatric and substance use disorders.

METHODS

Project CHANGE is an ongoing program to deliver person-centered, integrated care and services to individuals involved with the criminal justice system and experiencing homelessness. Applying a Screening, Brief Intervention, (Referral to) Treatment framework, a comprehensive needs assessment is followed by delivery of intensive housing and vocational case management; and psychiatric, substance use, and medical services in a single location by an interdisciplinary team. Participants are followed with study interviews for 12 months. The current analysis was designed to assess the baseline characteristics and needs of the sample population, and the intensity of contact required for integrated service delivery.

RESULTS

Between November 2019 and September 2021, 86 participants were enrolled, of whom 64% had been released from prison/jail in the past 6 months; the remainder were on parole, probation, or intensive pretrial supervision. Participants were unstably housed (64%) or residing outdoors (26.7%) or in a shelter (24.4%). Most participants had high medical need and frequent healthcare engagement through outpatient and emergency department visits. Most participants were at-risk for clinical depression, and half were diagnosed with anxiety, dissociative, stress-related, somatoform, and other non-psychotic psychiatric disorders. Over 12-month follow-up, the interdisciplinary team made over 500 contact encounters, over half of which resulted in direct services provided, including obtaining vital documents for homelessness verification, housing applications, and employment coaching.

CONCLUSION

Navigation of services can be particularly challenging for individuals experiencing criminal justice involvement, homelessness, and co-occurring medical, psychiatric, and substance use issues, which can be addressed holistically in an integrated service model. Integrated service delivery was time-, resource-, and staffing-intensive, and challenged by the COVID-19 pandemic, requiring innovative solutions to sustain participant engagement.

Radiographic Cortical Thickness Index Predicts Fragility Fracture in Gaucher Disease

Background Patients with Gaucher disease (GD) have a high risk of fragility fractures. Routine evaluation of bone involvement in these patients includes radiography and repeated dual-energy x-ray absorptiometry (DXA). However, osteonecrosis and bone fracture may affect the accuracy of DXA. Purpose To assess the utility of DXA and radiographic femoral cortical thickness measurements as predictors of fragility fracture in patients with GD with long-term follow-up (up to 30 years). Materials and Methods Patients with GD age 16 years and older with a detailed medical history, at least one bone image (DXA and/or radiographs), and minimum 2 years follow-up were retrospectively identified using three merged UK-based registries (Gaucherite study, enrollment 2015-2017; Clinical Bone Registry, enrollment 2003-2006; and Mortality Registry, enrollment 1993-2019). Cortical thickness index (CTI) and canal-to-calcar ratio (CCR) were measured by two independent observers, and inter- and intraobserver reliability was calculated. The fracture-predictive value of DXA, CTI, CCR, and cutoff values were calculated using receiver operating characteristic curves. Statistical differences were assessed using univariable and multivariable analysis. Results Bone imaging in 247 patients (123 men, 124 women; baseline median age, 39 years; IQR, 27-50 years) was reviewed. The median follow-up period was 11 years (IQR, 7-19 years; range, 2-30 years). Thirty-five patients had fractures before or at first bone imaging, 23 patients had fractures after first bone imaging, and 189 patients remained fracture-free. Inter- and intraobserver reproducibility for CTI/CCR measurements was substantial (range, 0.96-0.98). In the 212 patients with no baseline fracture, CTI (cutoff, ≤0.50) predicted future fractures with higher sensitivity and specificity (area under the receiver operating characteristic curve [AUC], 0.96; 95% CI: 0.84, 0.99; sensitivity, 92%; specificity, 96%) than DXA T-score at total hip (AUC, 0.78; 95% CI: 0.51, 0.91; sensitivity, 64%; specificity, 93%), femoral neck (AUC, 0.73; 95% CI: 0.50, 0.86; sensitivity, 64%; specificity, 73%), lumbar spine (AUC, 0.69; 95% CI: 0.49, 0.82; sensitivity, 57%; specificity, 63%), and forearm (AUC, 0.78; 95% CI: 0.59, 0.89; sensitivity, 70%; specificity, 70%). Conclusion Radiographic cortical thickness index of 0.50 or less was a reliable independent predictor of fracture risk in Gaucher disease. Clinical trial registration no. NCT03240653 © RSNA, 2022 Supplemental material is available for this article.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Elexacaftor, tezacaftor and ivacaftor: a case of severe rash and approach to desensitisation

We present a case of severe rash following induction of elexacaftor, tezacaftor and ivacaftor (ELX/TEZ/IVA) in a young adult male cystic fibrosis patient. While rash is a commonly reported side effect which resolves in 1-2 weeks with minimal intervention, our patient had presented with fever and widespread rash prompting medication cessation. After a washout period, reintroduction with 1/2 tablet of ELX/TEZ/IVA produced a similar systemic response within 24 hours. Repeat attempt, this time with 1/8 tablet and increasing in increments of an eighth daily, was successful and has allowed our patient to experience the transformative benefits of ELX/TEZ/IVA including improved pulmonary function and reduced episodes of infective exacerbation. This case illustrates one of the most common side effects of ELX/TEZ/IVA triple therapy, and our experience of desensitisation to ELX/TEZ/IVA in a challenging case of rash.

Daily red wine vinegar ingestion for eight weeks improves glucose homeostasis and affects the metabolome but does not reduce adiposity in adults

This is the first study to investigate the effects of vinegar on adiposity and glycemia using both anthropometrics and metabolomics.

A multifunctional aqueous channel formed by CFTR

The cystic fibrosis gene product (CFTR) is a complex protein that functions as an adenosine 3,5-monophosphate (cAMP)-stimulated ion channel and possibly as a regulator of intracellular processes. In order to determine whether the CFTR molecule contains a functional aqueous pathway, anion, water, and urea transport were measured in Xenopus oocytes expressing CFTR. Cyclic AMP agonists induced a Cl- conductance of 94 microsiemens and an increase in water permeability of 4 x 10(-4) centimeter per second that was inhibited by a Cl- channel blocker and was dependent on anion composition. CFTR has a calculated single channel water conductance of 9 x 10(-13) cubic centimeter per second, suggesting a pore-like aqueous pathway. Oocytes expressing CFTR also showed cAMP-stimulated transport of urea but not the larger solute sucrose. Thus CFTR contains a cAMP-stimulated aqueous pore that can transport anions, water, and small solutes. The results also provide functional evidence for water movement through an ion channel.

A continuous quality improvement team approach to adverse drug reaction reporting

Crossfunctional teams can generate more new ideas, concepts, and possible solutions than does a department-based process alone. Working collaboratively can increase knowledge of teams using CQI approaches and appropriate tools. CQI produces growth and development at multiple levels resulting from involvement in the process of incremental improvement.

Common-source epidemic of hepatitis due to glazed and iced pastries

Sixty-one clinical cases of hepatitis occurred in Ogemaw County, Michigan, in late April and May 1968. The clustering of cases in time and the high attack rate for persons 10-19 years of age suggested a common source of exposure. Investigation implicated a local bakery, where one of the employees directly involved in the baking had had an icteric illness one month before the outbreak. Comparison of exposure histories of patients versus healthy family members established pastries covered with glaze or icing as the vehicle of infection. The glaze and icing were applied to the pastries after all baking had been completed. During the epidemic, immune serum globulin was given on a community-wide basis. No secondary cases of hepatitis were identified.