Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings

BACKGROUND

A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner.

METHODS

We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000.

RESULTS

The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics.

CONCLUSIONS

While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

What trauma patients need: the European dilemma

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Problems and solutions in delivering global surgery in the 21st century

BACKGROUND

Surgery has had low priority in global health planning, so the delivery of surgical care in low- and middle-income countries is often poorly resourced. A recent Lancet Commission on Global Surgery has highlighted the need for change.

METHODS

A consensus view of the problems and solutions was identified by individual surgeons from high-income countries, familiar with surgical care in remote and poorer environments, based on recent publications related to global surgery.

RESULTS

The major issues identified were: the perceived unimportance of surgery, shortage of personnel, lack of appropriate training and failure to establish surgical standards, failure to appreciate local needs and poor coordination of service delivery.

CONCLUSION

Surgery deserves a higher priority in global health resource allocation. Lessons learned from participation in humanitarian crises should be considered in surgical developments.

N-Acetylprocainamide kinetics and clinical response during repeated dosing

Kinetics of and clinical responses to N-acetylprocainamide (NAPA) were evaluated in 10 patients with chronic ventricular arrhythmias who had not responded to usual doses of currently available antiarrhythmic drugs. Kinetic data analysis was by measured NAPA concentrations (n = 149) collected during repeated dosing. Response was evaluated with serial 24-hr ambulatory ECGs. An a priori kinetic model based on earlier studies predicted NAPA concentrations well (r = 0.94, SEE = 3.6 mg/l). The capability for defining patient-specific estimates for drug disposition with six or seven serum concentrations measured at the outset of therapy was subsequently confirmed with larger data sets from the same patients. Mean values for elimination rate (0.082 hr -1 +/- 0.017) and volume of distribution (1.25 l/kg +/- 0.28) were of the same order as in earlier single-dose studies. A substantial degree of interpatient and intrapatient variability in the absorption rate for NAPA was observed. NAPA was not found to be clinically effective in any of the 10 patients, although two patients demonstrated a greater than 70% reduction in frequency of premature ventricular contractions. There were adverse effects in all patients, which frequently required dose reduction or cessation of therapy. In this group of patients with resistant arrhythmias, NAPA was no more effective than baseline therapy, and adverse effects often limited complete evaluation. The kinetic analysis demonstrated the feasibility of a strategy for developing patient-specific kinetic models that may have applications to other antiarrhythmic drugs.