Articles

Understanding and Addressing the Global Need for Orthopaedic Trauma Care.

This article addresses the global burden of musculoskeletal trauma in particular in low and middle income countries.

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda

Background: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level.

Infectious Outcomes Assessment for Health System Strengthening in Low-Resource Settings: The Novel Use of a Trauma Registry in Rwanda

Background: More than 90% of injury deaths occur in low-income countries where a shortage of personnel, infrastructure, and materials challenge health system strengthening efforts. Trauma registries developed regionally have been used previously for injury surveillance in resource-limited settings, but scant outcomes data exist.

Identifying the Unique Non-Technical Skills Used by Surgeons Operating in Low and Middle Income Contexts

As surgical training and capacity increase in low- and middle-income countries (LMICs), new strategies for improving surgical education and care in resource-poor settings are required. Non-technical skills (NTS) have been identified as critical to high-quality surgical performance in high-income countries (HICs), but little is known about the NTS used by surgeons in LMICs. This study aims to identify the non-technical skills used by surgeons operating in a LMIC context.

Using a Trauma Registry and Quality Indicators to Evaluate Trauma Care in Rwanda

Injury is a leading cause of death in many limited resource settings. This study aimed to measure the quality of trauma care at the largest referral hospitals in Rwanda, the University Teaching Hospitals in Kigali and Butare,compared to international trauma care standards.

Development of the International Assessment of Capacity for Trauma (INTACT) Index: An Initial Implementation in Sierra Leone

Injury remains a leading cause of death worldwide with a disproportionate impact in the developing world. Capabilities for trauma care remain limited in these settings. Previous attempts have been made to assess basic trauma resources but have been limited to essential care. We propose the implementation of the International Assessment of Capacity for Trauma (INTACT) index, which incorporates surgical capacity beyond initial resuscitation.

Multilevel lumbosacral fusions: Complications and patient-reported outcome

The ageing population presents with debilitating back pain and leg pain with a background of adult spinal deformity, after a protracted period of conservative care. Sagittal balance is required to achieve a good clinical outcome; however, the surgery is associated with a high incidence of complications.

The Burden of Hand Injuries at a Tertiary Hospital in Sub-Saharan Africa

Necrotizing fasciitis is an infectious process characterized by rapidly progressing necrosis of superficial fascia and subcutaneous tissue with subsequent necrosis of overlying skin. Necrotizing fasciitis is a rare but fatal infection. The worldwide incidence is at 0.4 per 100,000. Mortality is up to 80% with no intervention, and 30-50% with intervention. Delay in intervention is associated with poor outcome. The risk factors for necrotizing fasciitis are diabetes mellitus, HIV, malignancy, illicit drug use, malnutrition among others. The aim of this study was to describe the clinical presentation and early outcomes of necrotizing fasciitis amongst Ugandan patients.

Tranexamic Acid Use in Severely Injured Civilian Patients and the Effects on Outcomes

 Objective: To characterize the relationship between tranexamic acid (TXA) use and patient outcomes in a severely injured civilian cohort, and to determine any differential effect between patients who presented with and without shock. Background: TXA has demonstrated survival benefits in trauma patients in an international randomized control trial and the military setting. The uptake of TXA into civilian major hemorrhage protocols (MHPs) has been variable. The evidence gap in mature civilian trauma systems is limiting the widespread use of TXA and its potential benefits on survival. Methods: Prospective cohort study of severely injured adult patients (Injury severity score > 15) admitted to a civilian trauma system during the adoption phase of TXA into the hospital's MHP. Outcomes measured were mortality, multiple organ failure (MOF), venous thromboembolism, infection, stroke, ventilator-free days (VFD), and length ofstay. Results: Patients receiving TXA (n = 160, 42%) were more severely injured, shocked, and coagulopathic on arrival. TXA was not independently associated with any change in outcome for either the overall or nonshocked cohorts. In multivariate analysis, TXA was independently associated with a reduction in MOF [odds ratio (OR) = 0.27, confidence interval (CI): 0.10–0.73, P = 0.01] and was protective for adjusted all-cause mortality (OR = 0.16 CI: 0.03–0.86, P = 0.03) in shocked patients. Conclusions: TXA as part of a major hemorrhage protocol within a mature civilian trauma system provides outcome benefits specifically for severely injured shocked patients. 

Evolution of trauma care in the UK: Current developments and future expectations

Major trauma is a major public health problem. It is the leading cause of death in people from the age of 1–40, accounting for one in ten deaths overall, and leads to significant morbidity.¹ Over the last 40 years many countries in the developed world have developed regionalised trauma systems to improve the survival rates of their patients who sustain traumatic injury.

Recommendations for including surgery on the public health agenda

Surgical care has made limited inroads on the public health and global health agendas despite increasing data showing the enormous need. The objective of this study was to survey interested members of a global surgery community to identify patterns of thought regarding barriers to political priority.

Task sharing within a managed clinical network to improve child health in Malawi

Background Eighty per cent of Malawi’s 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.

Prioritisation of surgery in the national health strategic plans of Africa: A systematic review

Disease amenable to surgical intervention accounts for 11-15 % of world disability and there is increasing interest in surgery as a global public health issue. National HealthStrategic Plans (NHSPs) reflect countries' long-term health priorities, plans and targets. These plans were analysed to assess the prioritisation of surgery as a public health issue inAfrica.NHSPs of 43 independent Sub-Saharan African countries available in the public domain in March 2014 in French or English were searched electronically for key terms: surg*, ortho*, trauma, cancer, appendic*, laparotomy, HIV, tuberculosis, malaria. They were then searched manually for disease prevalence, targets, and human resources.19 % of NHSPs had no mentionof surgery or surgical conditions. 63 % had five or less mentions of surgery. HIV and malaria had 3772 mentions across all the policies, compared to surgery with only 376 mentions. Trauma had 239 mentions, while the common surgical conditions of appendicitis, laparotomy and hernia had no mentions at all. Over 95 % of NHSPs specifically mentioned the prevalence of HIV, tuberculosis, malaria, infant mortality and maternal mortality. Whereas, the most commonly mentioned surgical condition for which a prevalence was given was trauma, in only 47 % of policies. All NHSPs had plans and measurable targets for the reduction of HIV and tuberculosis. Of the total 4064 health targets, only 2 % were related to surgical conditions or surgical care. 33 % of policies had no surgical targets.NHSPs are the best available measure of health service and planning priorities. It is clear from our findings that surgery is poorly represented and that surgical conditions and surgical treatment are not widely recognised as a public health priority. Greater prioritisation of surgery in national health strategic policies is required to build resilient surgical systems. Read the full article here.

The evidence needed to make surgery a global health priority

In their policy analysis, Yusra Ribhi Shawar and colleagues (August, 2015)¹ outline the complex responses needed to make surgery a global health priority, highlighting as a major challenge that “consensus needs to be reached on solutions”. Professional interests might have forestalled consensus on the need to train and supervise non-surgeons to deliver surgical services in places where surgeons cannot be retained.²However, sceptics are right to call, and donors to wait, for evidence on the feasibility, safety, cost-effectiveness, and outcomes of such models.

Injury assessment in three low-resource settings: a reference for worldwide estimates

Background Trauma has become a worldwide pandemic. Without dedicated public health interventions, fatal injuries will rise 40% and become the 4th leading cause of death by 2030, with the burden highest in low-income and middle-income countries (LMICs). The aim of this study was to estimate the prevalence of traumatic injuries and injury-related deaths in low-resource countries worldwide, using population-based data from the Surgeons OverSeas Assessment of Surgical Need (SOSAS), a validated survey tool.

Surgical care needs of low-resource populations: an estimate of the prevalence of surgically treatable conditions and avoidable deaths in 48 countries

Abstract: Background Surgical care needs in low-resource countries are increasingly recognised as an important aspect of global health, yet data for the size of the problem are insufficient. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a population-based cluster survey previously used in Nepal, Rwanda, and Sierra Leone. Methods Using previously published SOSAS data from three resource-poor countries (Nepal, Rwanda, and Sierra Leone), a weighted average of overall prevalence of surgically treatable conditions was estimated and the number of deaths that could have been avoided by providing access to surgical care was calculated for the broader community of low-resource countries. Such conditions included, but were not limited to, injuries (road traffic incidents, falls, burns, and gunshot or stab wounds), masses (solid or soft, reducible), deformities (congenital or acquired), abdominal distention, and obstructed delivery. Population and health expenditure per capita data were obtained from the World Bank. Low-resource countries were defined as those with a per capita health expenditure of US$100 or less annually. The overall prevalence estimate from the previously published SOSAS data was extrapolated to each low-resource country. Using crude death rates for each country and the calculated proportion of avoidable deaths, a total number of deaths possibly averted in the previous year with access to appropriate surgical care was calculated. Findings The overall prevalence of surgically treatable conditions was 11·16% (95% CI 11·15–11·17) and 25·6% (95% CI 25·4–25·7) of deaths were potentially avoidable by providing access to surgical care. Using these percentages for the 48 low-resource countries, an estimated 288·2 million people are living with a surgically treatable condition and 5·6 million deaths could be averted annually by the provision of surgical care. In the Nepal SOSAS study, the observed agreement between self-reported verbal responses and visual physical examination findings was 94·6%. Such high correlation helps to validate the SOSAS tool. Interpretation Hundreds of millions of people with surgically treatable conditions live in low-resource countries, and about 25% of the mortality annually could be avoided with better access to surgical care. Strengthening surgical care must be considered when strengthening health systems and in setting future sustainable development goals. Funding None.

The Specialist Surgeon Workforce in East, Central and Southern Africa: A Situation Analysis

In East, Central and Southern Africa accurate data on the current surgeon workforce have previously been limited. The surgical workforce in each of the ten member countries of the College of Surgeons of East, Central and Southern Africa (COSECSA) was determined by gathering and crosschecking data from multiple sources including COSECSA records, medical council registers, local surgical societies records, event attendance lists and interviews of Members and Fellows of COSECSA, and validating this by direct contact with the surgeons identified. 

Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings

In 2009, the Global Health Delivery Project collaborated with UpToDate to provide free subscriptions to qualifying health workers in resource-limited settings. 

Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia: A prospective study of 22 children (32 feet) from 2 to 10 years of age

We evaluated the effective- ness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.

Injury prevalence and causality in developing nations: Results from a countrywide population-based survey in Nepal

Traumatic injury affects nearly 5.8 million people annually and causes 10% of the world's deaths. In this study we aimed to estimate injury prevalence, to describe risk-factors and mechanisms of injury, and to estimate the number of injury-related deaths in Nepal, a low-income South Asian country.