Funding allocation to surgery in low and middle-income countries: a retrospective analysis of contributions from the USA

OBJECTIVE

The funds available for global surgical delivery, capacity building and research are unknown and presumed to be low. Meanwhile, conditions amenable to surgery are estimated to account for nearly 30% of the global burden of disease. We describe funds given to these efforts from the USA, the world's largest donor nation.

DESIGN

Retrospective database review. US Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center and registered US charitable organisations were searched for financial data on any organisation giving exclusively to surgical care in low and middle income countries (LMICs). For USAID, NIH and Foundation Center all available data for all years were included. The five recent years of financial data per charitable organisation were included. All nominal dollars were adjusted for inflation by converting to 2014 US dollars.

SETTING

USA.

PARTICIPANTS

USAID, NIH, Foundation Center, Charitable Organisations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cumulative funds appropriated to global surgery.

RESULTS

22 NIH funded projects (totalling $31.3 million) were identified, primarily related to injury and trauma. Six relevant USAID projects were identified-all obstetric fistula care totalling $438 million. A total of $105 million was given to universities and charitable organisations by US foundations for 12 different surgical specialties. 95 US charitable organisations representing 14 specialties totalled revenue of $2.67 billion and expenditure of $2.5 billion.

CONCLUSIONS AND RELEVANCE

Current funding flows to surgical care in LMICs are poorly understood. US funding predominantly comes from private charitable organisations, is often narrowly focused and does not always reflect local needs or support capacity building. Improving surgical care, and embedding it within national health systems in LMICs, will likely require greater financial investment. Tracking funds targeting surgery helps to quantify and clarify current investments and funding gaps, ensures resources materialise from promises and promotes transparency within global health financing.

Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis

BACKGROUND

Few population-based studies quantify mortality from surgical conditions and relate mortality to access to surgical care in low-income and middle-income countries.

METHODS

We linked deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million households in India to nationally representative facility data. We calculated total and age-standardised death rates for acute abdominal conditions. Using 4064 postal codes, we undertook a spatial clustering analysis to compare geographical access to well-resourced government district hospitals (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology) in high-mortality or low-mortality clusters from acute abdominal conditions.

FINDINGS

923 (1·1%) of 86,806 study deaths at ages 0-69 years were identified as deaths from acute abdominal conditions, corresponding to 72,000 deaths nationally in 2010 in India. Most deaths occurred at home (71%) and in rural areas (87%). Compared with 567 low-mortality geographical clusters, the 393 high-mortality clusters had a nine times higher age-standardised acute abdominal mortality rate and significantly greater distance to a well-resourced hospital. The odds ratio (OR) of being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 [95% CI 7·9-32·8] for >100 km). No such relation was seen for deaths from non-acute surgical conditions (ie, oral, breast, and uterine cancer).

INTERPRETATION

Improvements in human and physical resources at existing government hospitals are needed to reduce deaths from acute abdominal conditions in India. Full access to well-resourced hospitals within 50 km by all of India's population could have avoided about 50,000 deaths from acute abdominal conditions, and probably more from other emergency surgical conditions.

FUNDING

Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, Canadian Institute of Health Research.

The mitochondria-targeted anti-oxidant MitoQ decreases ischemia-reperfusion injury in a murine syngeneic heart transplant model

Background

Free radical production and mitochondrial dysfunction during cardiac graft reperfusion is a major factor in post-transplant ischemia-reperfusion (IR) injury, an important underlying cause of primary graft dysfunction. We therefore assessed the efficacy of the mitochondria-targeted anti-oxidant MitoQ in reducing IR injury in a murine heterotopic cardiac transplant model.

Methods

Hearts from C57BL/6 donor mice were flushed with storage solution alone, solution containing the anti-oxidant MitoQ, or solution containing the non–anti-oxidant decyltriphenylphosphonium control and exposed to short (30 minutes) or prolonged (4 hour) cold preservation before transplantation. Grafts were transplanted into C57BL/6 recipients and analyzed for mitochondrial reactive oxygen species production, oxidative damage, serum troponin, beating score, and inflammatory markers 120 minutes or 24 hours post-transplant.

Results

MitoQ was taken up by the heart during cold storage. Prolonged cold preservation of donor hearts before IR increased IR injury (troponin I, beating score) and mitochondrial reactive oxygen species, mitochondrial DNA damage, protein carbonyls, and pro-inflammatory cytokine release 24 hours after transplant. Administration of MitoQ to the donor heart in the storage solution protected against this IR injury by blocking graft oxidative damage and dampening the early pro-inflammatory response in the recipient.

Conclusions

IR after heart transplantation results in mitochondrial oxidative damage that is potentiated by cold ischemia. Supplementing donor graft perfusion with the anti-oxidant MitoQ before transplantation should be studied further to reduce IR-related free radical production, the innate immune response to IR injury, and subsequent donor cardiac injury.

Catastrophic expenditure to pay for surgery worldwide: a modelling study

BACKGROUND

Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery.

METHODS

To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model.

FINDINGS

3·7 billion people (posterior credible interval 3·2-4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8-81·7 million) worldwide are driven to financial catastrophe-32·8 million (32·4-33·1 million) from the costs of surgery alone and 48·5 million (47·7-49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions.

INTERPRETATION

Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design.

FUNDING

MGS received partial funding from NIH/NCI R25CA92203.

Deaths from acute abdominal conditions and geographic access to surgical care in India: a nationally representative population-based spatial analysis

BACKGROUND

Acute abdominal conditions have high case-fatality rates in the absence of timely surgical care. In India, and many other low-income and middle-income countries, few population-based studies have quantified mortality from surgical conditions and related mortality to access to surgical care. We aimed to describe the spatial and socioeconomic distributions of deaths from acute abdomen (DAA) in India and to quantify potential access to surgical facilities in relation to such deaths.

METHODS

We examined deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million Indian households and linked these to nationally representative facility data. Spatial clustering of deaths from acute abdominal conditions was calculated with the Getis-Ord Gi* statistic from about 4000 postal codes. We compared high or low acute abdominal mortality clusters for their geographic access to well-resourced surgical care (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology).

FINDINGS

923 (1·1%) of 86 806 study deaths in those aged 0-69 years were identified as deaths from acute abdominal conditions, corresponding to an estimated 72 000 deaths nationally in India in 2010. Most deaths occurred at home (71%), in rural areas (87%), and were caused by peptic ulcer disease (79%). There was wide variation in rates of deaths from acute abdominal conditions. We identified 393 high-mortality geographic clusters and 567 low-mortality clusters. High-mortality clusters of acute abdominal conditions were located significantly further from well-resourced hospitals than were low-mortality clusters. The odds ratio of a postal code area being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 for >100 km), after adjustment for socioeconomic status and caste.

INTERPRETATION

Improvements in human and physical resources at existing public hospitals are required to reduce deaths from acute abdominal conditions in India. Had all of the Indian population had access to well-resourced hospitals within 50 km, more than 50 000 deaths from acute abdominal conditions could have been averted in 2010, and likely more from other emergency surgical conditions. Our geocoded facility data were limited to public district hospitals. However, noting the high rate of catastrophic health expenditures in India, we chose to focus on publicly provided services which are the only option usually available to the poor.

FUNDING

The Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, and Canadian Institute of Health Research.

Funding flows to global surgery: an analysis of contributions from the USA

BACKGROUND

In recent years, funds for global health have risen substantially, particularly for infectious diseases. Although conditions amenable to surgery account for 28% of the global burden of disease, the external funds directed towards global surgical delivery, capacity building, and research are currently unknown and presumed to be low. We aimed to describe external funds given to these efforts from the USA, the world's largest donor nation.

METHODS

We searched the United States Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center, and registered US charitable organisations databases for financial data on any giving exclusively to surgical care in low-income and middle-income countries (LMICs). All nominal dollars were adjusted for inflation by converting to 2014 US dollars.

FINDINGS

After adjustment for inflation, 22 NIH funded projects (totalling US$31·3 million, 1991-2014) were identified; 78·9% for trauma and injury, 12·5% for general surgery, and 8·6% for ophthalmology. Six relevant USAID projects were identified; all related to obstetric fistula care totalling US$438 million (2006-13). US$105 million (2003-13) was given to universities and charitable organisations by US foundations for 14 different surgical specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, burn, general surgery, obstetric emergency procedures, anaesthesia, and unspecified specialty). 95 US charitable organisations representing 14 specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, urology, ENT, craniofacial, burn, and general surgery) totalled revenue of US$2·67 billion and expenditure of US$2·5 billion (2007-13).

INTERPRETATION

A strong surgical system is an indispensable part of any health system and requires financial investment. Tracking funds targeting surgery helps not only to quantify and clarify this investment, but also to ultimately serve as a platform to integrate surgical spending within health system strengthening. Although USAID is a vital foreign aid service and the NIH is a leader in biomedical and health research, their surgical scopes are restricted both financially (less than 1% of respective total budgets over the study years) and in surgical specialty. By contrast, the private charitable sector has contributed more financially and to more specialties. Still, current financial global health databases do not have precise data for surgery. To improve population health in LMICs, more resources should be dedicated to surgical system strengthening. Furthermore, exact classification measures should be implemented to track these important resources.

FUNDING

None.

Financial contribution to global surgery: an analysis of 160 international charitable organisations

BACKGROUND

The non-profit and volunteer sector provides substantial contributions to global health. Within the field of surgery, this sector has made notable service contributions in low-income and middle-income countries (LMICs) where access to surgical care is poor. Little is known about financing and funding flows to surgical care in LMICs from both domestic and international sources. Because an estimated 55% of surgical care delivered in LMICs is via charitable organisations, understanding the financial contributions of this sector could provide valuable insight into estimating funding flows and understanding financing priorities in global surgery.

METHODS

Between June, and September, 2014, we searched public online databases of registered charitable organisations in five high-income nations (the USA, the UK, Canada, Australia, and New Zealand) to identify organisations committed exclusively to surgical needs. Based on availability, the most current 5 years (2007-13) of financial data per organisation were collected. For each charitable organisation, we identified the type of surgical services provided. We examined revenues and expenditures for each organisation.

FINDINGS

160 organisations representing 15 different surgical specialties were included in the analysis. Total aggregated revenue over the years 2008-2013 was US$3·3 billion. Total aggregated expenses for all 160 organisations amounted to US$3·0 billion. 28 ophthalmology organisations accounted for 45% of revenue and 49% of expenses. 15 cleft lip and palate organisations totalled 26% of both revenue and expenses. 19 organisations providing a mix of diverse surgical specialty services amounted to 14% of revenue and 16% of expenses. The remaining 15% of funds represented 12 specialties and 98 organisations. The US accounted for 77·7% of revenue and 80·8% of expenses. The UK accounted for 11·0% of revenue and 11·91% of expenses. Canada accounted for 1·85% of revenue and 2·01% of expenses. Australia and New Zealand accounted for 4·94% of revenue and 5·29% of expenses.

INTERPRETATION

Charitable organisations addressing surgical conditions primarily focus on elective surgical care and cover a broad range of subspecialties. The largest funding flows from charitable organisations are directed at ophthalmology, followed by cleft lip and palate surgery. However, there is a clear need for improved, transparent tracking of funds to global surgery via charitable organisations.

FUNDING

None.

Demographics of patients affected by surgical disease in rural hospitals in two sub-Saharan African countries: a retrospective analysis

BACKGROUND

Awareness is growing of both the importance of surgical disease as a major cause of death and disability in low-income and middle-income countries (LMICs) and the cost-effectiveness of fairly simple surgical interventions. We hypothesised that surgical disease predominantly affects young adults and is therefore significant in both the macroeconomic effect of untreated disease and the microeconomic effects on patients and families in low-resource settings.

METHODS

We retrospectively reviewed all admission data from two rural government district hospitals, Bo District Hospital in Sierra Leone and Thyolo District Hospital in Malawi. Both hospitals serve a rural population of roughly 600 000. We analysed data from 3 months in the wet season and 3 months in the dry season for each hospital by careful analysis of all hospital logbook data. For the purposes of this study, a surgical diagnosis was defined as a diagnosis in which the patient should be managed by a surgically trained provider. We analysed all surgical admissions with respect to patient demographics (age and sex), diagnoses, and the procedures undertaken.

FINDINGS

In Thyolo, 835 (12·9%) of 6481 hospital admissions were surgical admissions. In Bo, 427 (19·8%) of 2152 hospital admissions were surgical admissions. In Thyolo, if all patients who had undergone a procedure in theatre were admitted overnight, the total number of admissions would have been 6931, with 1344 (19·4%) hospital admissions being surgical and 1282 (18·5%) hospital patients requiring a surgical procedure. In Bo, 133 patients underwent a surgical procedure. This corresponded to 6·18% of all hospital admissions; although notably many of the obstetric admissions were referred to a nearby Médecins Sans Frontières (MSF) hospital for treatment. Analysis of the admission data showed that younger than 16-year-olds accounted for 10·5% of surgical admissions in Bo, and 17·9% of surgical admissions in Thyolo. 16-35-year-olds accounted for 57·3% of all surgical admissions in Bo and 53·5% of all surgical admissions in Thyolo. Men accounted for 53·7% of surgical admissions in Bo and 46·0% of surgical admissions in Thyolo. Analysis of the procedure data showed that younger than 16-year-olds accounted for 7·0% of procedures in Bo and 4·5% of procedures in Thyolo, with 16-35-year-olds accounting for 65·6% of all procedures in Bo and 84·4% of all procedures in Thyolo. Men underwent 63% of all surgical procedures in Bo, but only 7·7% of surgical procedures in Thyolo. This discrepancy is explained by the high rate of maternal surgery in Thyolo, which was not present in Bo because this service was provided at the nearby MSF hospital.

INTERPRETATION

Most people affected by disease requiring surgery are young adults. It would be expected that failure to provide surgical care could have long-term adverse effects on both individual and national wealth.

FUNDING

The Sir Ratanji Dalal Scholarship from the Royal College of Surgeons of England.

Global economic consequences of selected surgical diseases: a modelling study

BACKGROUND

The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives.

METHODS

We obtained mortality rate estimates for each disease for the years 2000 and 2010 from the Institute of Health Metrics and Evaluation Global Burden of Disease 2010 study, and estimates of the proportion of the burden of the selected diseases that is surgical from a paper by Shrime and colleagues. We first used the value of lost output (VLO) approach, based on the WHO's Projecting the Economic Cost of Ill-Health (EPIC) model, to project annual market economy losses due to these surgical diseases during 2015-30. EPIC attempts to model how disease affects a country's projected labour force and capital stock, which in turn are related to losses in economic output, or gross domestic product (GDP). We then used the value of lost welfare (VLW) approach, which is conceptually based on the value of a statistical life and is inclusive of non-market losses, to estimate the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses were performed for both approaches.

FINDINGS

During 2015-30, the VLO approach projected that surgical conditions would result in losses of 1·25% of potential GDP, or $20·7 trillion (2010 US$, purchasing power parity) in the 128 countries with data available. When expressed as a proportion of potential GDP, annual GDP losses were greatest in low-income and middle-income countries, with up to a 2·5% loss in output by 2030. When total welfare losses are assessed (VLW), the present value of economic losses is estimated to be equivalent to 17% of 2010 GDP, or $14·5 trillion in the 175 countries assessed with this approach. Neoplasm and injury account for greater than 95% of total economic losses with each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries with the VLW approach, contribute to 26% of losses in low-income countries.

INTERPRETATION

The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favourable cost-effectiveness analyses of surgical interventions in low-income and middle-income countries, our results suggest that building surgical capacity should be a global health priority.

FUNDING

US National Institutes of Health/National Cancer Institute.

Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries

BACKGROUND

Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs.

METHODS

We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised.

FINDINGS

In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention.

INTERPRETATION

Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs.

FUNDING

The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.

Kidney donation after circulatory death (DCD): state of the art

Ischemia–reperfusion (IR) injury to the kidney occurs in a range of clinically important scenarios including hypotension, sepsis and in surgical procedures such as cardiac bypass surgery and kidney transplantation, leading to acute kidney injury (AKI). Mitochondrial oxidative damage is a significant contributor to the early phases of IR injury and may initiate a damaging inflammatory response. Here we assessed whether the mitochondria targeted antioxidant MitoQ could decrease oxidative damage during IR injury and thereby protect kidney function. To do this we exposed kidneys in mice to in vivo ischemia by bilaterally occluding the renal vessels followed by reperfusion for up to 24 h. This caused renal dysfunction, measured by decreased creatinine clearance, and increased markers of oxidative damage. Administering MitoQ to the mice intravenously 15 min prior to ischemia protected the kidney from damage and dysfunction. These data indicate that mitochondrial oxidative damage contributes to kidney IR injury and that mitochondria targeted antioxidants such as MitoQ are potential therapies for renal dysfunction due to IR injury.

Ischaemic accumulation of succinate controls reperfusion injury through mitochondrial ROS

Ischaemia-reperfusion injury occurs when the blood supply to an organ is disrupted and then restored, and underlies many disorders, notably heart attack and stroke. While reperfusion of ischaemic tissue is essential for survival, it also initiates oxidative damage, cell death and aberrant immune responses through the generation of mitochondrial reactive oxygen species (ROS). Although mitochondrial ROS production in ischaemia reperfusion is established, it has generally been considered a nonspecific response to reperfusion. Here we develop a comparative in vivo metabolomic analysis, and unexpectedly identify widely conserved metabolic pathways responsible for mitochondrial ROS production during ischaemia reperfusion. We show that selective accumulation of the citric acid cycle intermediate succinate is a universal metabolic signature of ischaemia in a range of tissues and is responsible for mitochondrial ROS production during reperfusion. Ischaemic succinate accumulation arises from reversal of succinate dehydrogenase, which in turn is driven by fumarate overflow from purine nucleotide breakdown and partial reversal of the malate/aspartate shuttle. After reperfusion, the accumulated succinate is rapidly re-oxidized by succinate dehydrogenase, driving extensive ROS generation by reverse electron transport at mitochondrial complex I. Decreasing ischaemic succinate accumulation by pharmacological inhibition is sufficient to ameliorate in vivo ischaemia-reperfusion injury in murine models of heart attack and stroke. Thus, we have identified a conserved metabolic response of tissues to ischaemia and reperfusion that unifies many hitherto unconnected aspects of ischaemia-reperfusion injury. Furthermore, these findings reveal a new pathway for metabolic control of ROS production in vivo, while demonstrating that inhibition of ischaemic succinate accumulation and its oxidation after subsequent reperfusion is a potential therapeutic target to decrease ischaemia-reperfusion injury in a range of pathologies.

Additive effect of pretransplant obesity, diabetes, and cardiovascular risk factors on outcomes after liver transplantation

The effects of pretransplant obesity, diabetes mellitus (DM), coronary artery disease (CAD), and hypertension (HTN) on outcomes after liver transplantation (LT) are controversial. Questions have also been raised about the appropriateness of the body mass index (BMI) for assessing obesity in patients with end-stage liver disease. Both issues have implications for organ allocation in LT. To address these questions, we undertook a cohort study of 202 consecutive patients (2000-2010) undergoing LT at a national center in New Zealand. BMI and body fat percentage (%BF) values (dual-energy X-ray absorptiometry) were measured before transplantation, and the methods were compared. The influence of pretransplant risk variables (including obesity, DM, CAD, and HTN) on the 30-day postoperative event rate, length of hospital stay, and survival were analyzed. There was agreement between the calculated BMI and the measured %BF for 86.0% of the study population (κ coefficient = 0.73, 95% confidence interval = 0.61-0.85), and this was maintained across increasing Model for End-Stage Liver Disease scores. Obesity was an independent risk factor for the postoperative event rate [count ratio (CR) = 1.03, P < 0.001], as was DM (CR = 1.4, P < 0.001). Obesity with concomitant DM was the strongest predictor of the postoperative event rate (CR = 1.75, P < 0.001) and a longer hospital stay (5.81 days, P < 0.01). Independent metabolic risk factors had no effect on 30-day, 1-year, or 5-year patient survival. In conclusion, BMI is an adequate tool for assessing obesity-associated risk in LT. Early post-LT morbidity is highest for patients with concomitant obesity and DM, although these factors do not appear to influence recipient survival.

Critical care of the potential organ donor

Organ transplantation represents one of the great success stories of 20th century medicine. However, its continued success is greatly limited by the shortage of donor organs. This has led to an increased focus within the critical care community on optimal identification and management of the potential organ donor. The multi-organ donor can represent one of the most complex intensive care patients, with numerous competing physiological priorities. However, appropriate management of the donor not only increases the number of organs that can be successfully donated but has long-term implications for the outcomes of multiple recipients. This review outlines current understandings of the physiological derangements seen in the organ donor and evaluates the available evidence for management strategies designed to optimize donation potential and organ recovery. Finally, emerging management strategies for the potential donor are discussed within the current ethical and legal frameworks permitting donation after both brain and circulatory death.

Setting up new learning environments in regional and rural areas

The shortage of doctors in New Zealand, especially in regional and rural areas, together with the recognition that medical students need to learn in a variety of contexts has led to new learning environments being developed. This paper describes some of the key factors that have led to the successful implementation of year-long regional and rural clinical placements for medical students in New Zealand.

A systematic review of experimental treatments for mitochondrial dysfunction in sepsis and multiple organ dysfunction syndrome

Sepsis and multiple organ dysfunction syndrome (MODS) are major causes of morbidity and mortality in the intensive care unit. Recently mitochondrial dysfunction has been proposed as a key early cellular event in critical illness. A growing body of experimental evidence suggests that mitochondrial therapies are effective in sepsis and MODS. The aim of this article is to undertake a systematic review of the current experimental evidence for the use of therapies for mitochondrial dysfunction during sepsis and MODS and to classify these mitochondrial therapies. A search of the MEDLINE and PubMed databases (1950 to July 2009) and a manual review of reference lists were conducted to find experimental studies containing data on the efficacy of mitochondrial therapies in sepsis and sepsis-related MODS. Fifty-one studies were included in this review. Five categories of mitochondrial therapies were defined-substrate provision, cofactor provision, mitochondrial antioxidants, mitochondrial reactive oxygen species scavengers, and membrane stabilizers. Administration of mitochondrial therapies during sepsis was associated with improvements in mitochondrial electron transport system function, oxidative phosphorylation, and ATP production and a reduction in cellular markers of oxidative stress. Amelioration of proinflammatory cytokines, caspase activation, and prevention of the membrane permeability transition were reported. Restoration of mitochondrial bioenergetics was associated with improvements in hemodynamic parameters, organ function, and overall survival. A substantial body of evidence from experimental studies at both the cellular and the organ level suggests a beneficial role for the administration of mitochondrial therapies in sepsis and MODS. We expect that mitochondrial therapies will have an increasingly important role in the management of sepsis and MODS. Clinical trials are now required.

Prepared for practice? Medical students' perceptions of a shortened final year medical programme

BACKGROUND In preparation to work as junior doctors (JD), University of Auckland final year medical students (FYMS) work as apprentices attached to hospital teams and general practices. Because of anecdotal evidence of student stress, a shortened academic year was introduced in 2007 (42 instead of 47 weeks).

AIM

To determine FYMS perceptions of the final-year medical course and whether or not these perceptions changed in the cohort undergoing a shortened academic year.

METHODS

All 2006 FYMS completing a 47-week year, and all 2007 FYMS completing a shortened 42-week year, were invited to complete a questionnaire on the final academic day.

RESULTS

116/136 (85.3%) and 118/132 (89.4%) of FYMS completed the questionnaire in the 2006 and 2007 cohorts respectively. Significantly fewer students in the 2007 cohort perceived that the year was "a little too long" (10.1% vs 24%, p=0.001), however this did not alter reported stress levels. The mean (-/+SD) Perceived Stress Scale's were 21.7-/+7.0 (2006) and 21.2-/+7.4 (2007), which are similar to the general population (19.6-/+7.5, range 0-45). Visual analog ratings (0-100) showed FYMS felt the programme was enjoyable 72.4-/+18.1, 73.9-/+17.9, despite feeling a degree of pressure 51.2-/+21.3, 47.19-/+20.31 and fatigue 51.4-/+20.3, 53.2-/+21.3. FYMS were largely happy with their decision to become doctors 75.9-/+18.5, 76.2-/+21.1 and felt mostly prepared 60.6-/+18.7, 62.3-/+20.8 but anxious 63.1-/+23.5, 57.7-/+24.4 about working as a JD the following year (all p<0.05). 76% and 73% of the 2006 and 2007 cohort reported being at least adequately prepared for their first house officer role (visual analogue score =50). Both the 2006 and 2007 cohorts considered their elective, general medical, general surgical, and radiology attachments of greatest use.

CONCLUSION

Shortening the academic year did not significantly alter perceived stress levels, however significantly fewer students did report finding the year "too long". Although FYMS felt ready to work as JDs, they were anxious but not more stressed than the general population about this transition. Attachments that were most valued by FYMS were those that were most closely aligned with the first year JD role.

What can the history tell us? An argument for observed history-taking in the trainee intern long case assessment

History-taking is one of the most important clinical skills for the medical student to learn and remains the core component of a doctor's diagnostic 'toolkit'. Yet, it is one of the most difficult clinical skills to assess. Clinical assessment at a trainee intern level has typically focussed on examination skills, and case presentation, which are more easily measured. History-taking is assumed to be of an adequate standard on the basis of the case presentation rather than by direct observation. In this paper we discuss the importance of assessing the patient-doctor encounter directly through observation, in the context of the trainee intern long case examination. Despite changing assessment trends in medical education, these authors argue for the retention of the long case as an assessment tool for final year medical students on the basis of its high face validity and close resemblance to "real life" patient encounters. However, we believe addition of an observing examiner during the history-taking and physical examination augments the inherent value of the longcase and is recommended in order to increase the reliability of the assessment. Observation allows for direct assessment of the student-patient interaction and the hypothetico-deductive approach taken by the student to diagnosis. It provides opportunity to reconcile the multiple interactions occurring between the context and the construct (skills and knowledge) measured in an assessment. Importantly, at a trainee intern level it provides students with a final opportunity to receive feedback on their history taking and diagnostic skills, an integral part of all medical practice, prior to their graduation as junior doctors.

Shifting perceptions and challenging the profession's paradigms: reflections from an undergraduate week of population health

The perception that population health is a poor cousin of the clinically orientated medical specialties has occurred despite a growing acknowledgement of the importance of a population health approach to the provision of medical care in the 21st Century. This perception appears entrenched within academic and clinical institutions, and is inherited by undergraduate students as they move through their training. Competing philosophies within modern medical curricula, medical socialisation, and historical professional belief structures have all contributed to both a covert and an overt scepticism towards population based approaches as being 'soft' and largely irrelevant. In May 2007, the University of Auckland introduced a new initiative for Year 5 medical students, called 'Population Health Intensive'. This was a week aimed at increasing medical undergraduate student's exposure to population health perspectives and initiatives. It challenged students and academic staff alike to reflect on their perceptions of the role of population health in medical practice and raised questions about the relevance of current medical education in light of the changing face of health and healthcare delivery. In this paper we consider the drivers of change and argue that population health has an important and legitimate place in both undergraduate medical training and clinical practice, thus widening the professions' understanding of health and disease.

Changes in plasminogen activator inhibitor-1 levels in non-small cell lung cancer

Increased urokinase plasminogen activator (uPA) levels are increased in a number of malignancies and have been correlated with decreased disease-free interval and decreased overall survival. We have, therefore, examined components of this plasminogen activating system in patients with Non-Small Cell Lung Cancer (NSCLC). Levels of uPA, urokinase-plasminogen activator receptor (uPAR) and plasminogen activator inhibitor-1 (PAI-1) were measured semiquantitatively in paraffin sections of tumours from 147 patients with NSCLC. Immunohistochemically stained sections of tumour were allocated a score for stain intensity and results correlated to: survival; tumour stage(T); nodal stage(N); stage grouping (I to IIIb), survival status and sex. Increased levels of PAI-1 were associated with a decreased survival in squamous cell carcinoma (SCC) X2 = 5.72, p = 0.017 (n = 74). There was a significant positive relationship between PAI-1 levels and N-stage (p = < 0.05), presence of nodal metastases (p = < 0.05), stage grouping (p = < 0.01) and extent of disease (p = < 0.05) in the total group and the SCC subgroup, but not adenocarcinoma. There was a significant positive relationship between PAI-1 levels and T-stage (p = < 0.05) in the total group, and survival status (p = < 0.05) in the SCC subgroup alone. uPA and uPAR levels were not significantly associated with tumour staging or survival. We conclude that increased PAI-1 antigen levels may be associated with a decreased survival in patients with SCC.