Surgical Capacity at District Hospitals in Zambia: From 2012 to 2016

What to scale first? A cross-sectional analysis of factors affecting cesarean delivery rates at first referral units in Bihar, India

BACKGROUND

Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates.

OBJECTIVES

We aimed to determine caesarean delivery rates at Bihar's first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates.

METHODS

This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018-March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates.

RESULTS

Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0-10), 39% had an anaesthetist (range 0-5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0-4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9-55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1-1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3-1.9, p < 0.001) were associated with facility-level CD rates.

CONCLUSION

Only 3.1% of the institutional childbirths in Bihar's FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

Review of the Current Situation of Postoperative Pain and Causes of Inadequate Pain Management in Africa

Postoperative pain is one of the most prevalent complications following surgery, and more than 47% of surgical patients endure postoperative discomfort worldwide. In Africa, due to resource shortages and other issues, postoperative pain is substantially more common when compared to developed countries. Severe postoperative pain has many negative effects, including possibly death, which can burden both individuals and society as a whole. Therefore, effectively controlling postoperative pain is becoming increasingly important. To enhance the effectiveness of future pain management, a thorough analysis of the current reasons for inadequate postoperative pain management is necessary. In this article, the present situations of occurring postoperative pain, children's postoperative pain, and pain management in Africa are reviewed, based on relevant and recent literature. In particular, the reasons for inadequate postoperative pain management in Africa are detailed in this article from five perspectives: the inadequate assessment of postoperative pain, the knowledge gap among medical professionals, the patients' misconceptions, the scarcity of resources, and the lack of medications. Additionally, we offer appropriate solutions following various factors.

The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa

BACKGROUND

In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA, has the highest trauma burden in the Cape Metro East health district.

OBJECTIVES

The primary objective of this study was to describe the impact of Khayelitsha District Hospital (KDH) on acute orthopaedic services in the health district, with a focus on the volume and type of orthopaedic services provided without tertiary referral.

METHODS

This retrospective analysis described acute orthopaedic cases from Khayelitsha and their management between 1 January 2018 and 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district are described.

RESULTS

In 2018 - 2019, KDH performed 2 040 orthopaedic operations, of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared with other DHs (0.92 - 1.35). In Khayelitsha, 2 402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism of injury for acute orthopaedic referrals. Of clinic cases, 2 229 (92.8%) were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157; 90.8%).

CONCLUSION

This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared with other DHs with fewer resources. Further research on the barriers to scaling up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.

Surgical capacity, productivity and efficiency at the district level in Sub-Saharan Africa: A three-country study

INTRODUCTION

Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries.

METHODS

Three-month data, comprising surgical capacity indicators and volumes of major surgical procedures collected from 61 district-level hospitals in Malawi, Tanzania, and Zambia, were analysed. Data envelopment analysis was used to calculate average hospital efficiency scores (max. = 1) for each country. Quantile regression analysis was selected to estimate the relationship between surgical volume and production factors. Two-stage bootstrap regression analysis was used to estimate the determinants of hospital efficiency.

RESULTS

Average hospital efficiency scores were 0.77 in Tanzania, 0.70 in Malawi and 0.41 in Zambia. Hospitals with high efficiency scores had significantly more surgical staff compared with low efficiency hospitals (DEA score<1). Hospitals that scored high on the most commonly utilised surgical capacity index were not the ones with high surgical volumes or high efficiency. The number of surgical team members, which was lowest in Zambia, was strongly, positively correlated with surgical productivity and efficiency.

CONCLUSION

Hospital efficiency, combining capacity measures and surgical outputs, is a better indicator of surgical performance than capacity measures, which could be misleading if used alone for surgical planning. Investment in the surgical workforce, in particular, is critical to improving district hospital surgical productivity and efficiency.

Barriers to increase surgical productivity in Sierra Leone: a qualitative study

OBJECTIVE

To explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017.

DESIGN AND METHODS

This explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework.

PARTICIPANTS AND SETTING

21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone.

RESULTS

Surgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity.

DISCUSSION

Broader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.

Policy options for surgical mentoring: Lessons from Zambia based on stakeholder consultation and systems science

BACKGROUND

Supervision by surgical specialists is beneficial because they can impart skills to district hospital-level surgical teams. The SURG-Africa project in Zambia comprises a mentoring trial in selected districts, involving two provincial-level mentoring teams. The aim of this paper is to explore policy options for embedding such surgical mentoring in existing policy structures through a participatory modeling approach.

METHODS

Four group model building workshops were held, two each in district and central hospitals. Participants worked in a variety of institutions and had clinical and/or administrative backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph theory was used to analyze the integrated CLD, and dynamic system behavior was explored using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL) method.

RESULTS

The establishment of a provincial mentoring faculty, in collaboration with key stakeholders, would be a necessary step to coordinate and sustain surgical mentoring and to monitor district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators need to closely monitor mentee motivation.

CONCLUSIONS

Surgical mentoring can play a key role in scaling up district-level surgery but its implementation is complex and requires designated provincial level coordination and regular contact with relevant stakeholders.

Nationwide enumeration of emergency operations performed in Ghana

PURPOSE

To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project.

RESULTS

Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations.

CONCLUSIONS

Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.

Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017

BACKGROUND

The Lancet Commission on Global Surgery recommends a minimum of 20 surgical specialists and 5,000 annual operations per 100,000 population by 2030. In 2012, Sierra Leone was far from reaching these targets. This study aimed to assess the changes in surgical activity, surgical workforce, and surgical productivity between 2012 and 2017.

METHODS

A nationwide, retrospective mapping of surgical activity and workforce in 2012 was repeated in 2017. All 60 facilities performing comprehensive surgery in Sierra Leone in 2017 were identified and data was obtained from surgical records and through structured interviews with facility directors. Annual estimates were calculated and compared with 2012.

RESULTS

The surgical workforce increased from 164.5 to 312.8 full-time positions. The annual volume of surgeries was enhanced by 15.6% (95% CI: 7.8-23.4%) from 24,152 to 27,928 (26,048-29,808) operations. With simultaneous population growth, this led to a decrease in surgical volume from 400 to 372 procedures per 100,000 population and an unmet operative need of 92.7%. The mean productivity of surgical providers went from 2.8 to 1.7 surgeries per week per full-time position. An increasing number of caesarean deliveries were performed in public institutions, by associate clinicians.

CONCLUSION

The unmet need for surgery in Sierra Leone remains very high, despite an increase in the surgical workforce, subsidizing maternal healthcare, and initiation of a surgical task-sharing program. The decline in surgical productivity with simultaneous increases in the surgical workforce calls for further exploration of the barriers to access and delivery of surgical care in Sierra Leone.

Surgical care in district hospitals in sub-Saharan Africa: a scoping review

OBJECTIVE

To provide a general overview of the reported current surgical capacity and delivery in order to advance current knowledge and suggest targets for further development and research within the region of sub-Saharan Africa.

DESIGN

Scoping review.

SETTING

District hospitals in sub-Saharan Africa.

DATA SOURCES

PubMed and Ovid EMBASE from January 2000 to December 2019.

STUDY SELECTION

Studies were included if they contained information about types of surgical procedures performed, number of operations per year, types of anaesthesia delivered, cadres of surgical/anaesthesia providers and/or patients' outcomes.

RESULTS

The 52 articles included in analysis provided information about 16 countries. District hospitals were a group of diverse institutions ranging from 21 to 371 beds. The three most frequently reported procedures were caesarean section, laparotomy and hernia repair, but a wide range of orthopaedics, plastic surgery and neurosurgery procedures were also mentioned. The number of operations performed per year per district hospital ranged from 239 to 5233. The most mentioned anaesthesia providers were non-physician clinicians trained in anaesthesia. They deliver mainly general and spinal anaesthesia. Depending on countries, articles referred to different surgical care providers: specialist surgeons, medical officers and non-physician clinicians. 15 articles reported perioperative complications among which surgical site infection was the most frequent. Fifteen articles reported perioperative deaths of which the leading causes were sepsis, haemorrhage and anaesthesia complications.

CONCLUSION

District hospitals play a significant role in sub-Saharan Africa, providing both emergency and elective surgeries. Most procedures are done under general or spinal anaesthesia, often administered by non-physician clinicians. Depending on countries, surgical care may be provided by medical officers, specialist surgeons and/or non-physician clinicians. Research on safety, quality and volume of surgical and anaesthesia care in this setting is scarce, and more attention to these questions is required.

Surgical Outcomes after Myelomeningocele Repair in Lusaka, Zambia

OBJECTIVE

Spina bifida disproportionally affects low-and-middle-income countries. We describe myelomeningocele surgical outcomes in Zambia and predictors of postoperative complications and mortality.

METHODS

This 2-center retrospective cohort study includes children who underwent surgical treatment for myelomeningocele in Lusaka, Zambia from 2017 to 2019. Primary outcomes included mortality and 30-day postoperative complications.

RESULTS

Seventy-five patients were identified. Median age at first neurosurgical evaluation was 9 days (interquartile range [IQR], 6-21) and at surgery was 21 days (IQR 15-36). Lumbosacral myelomeningocele was most common (73%, n = 54). At first preoperative evaluation, 28% of the neural tube defects were deemed infected (n = 21), and 30% were leaking cerebrospinal fluid (n = 21). Postoperatively, 7% of patients died (n = 5), whereas 31% experienced a complication (n = 23). Most common complications included wound dehiscence (n = 10, 42%) and wound purulence (n = 6, 25%). Median follow-up duration was 41 days (IQR, 6-128). On univariable analysis, mortality was significantly associated with shorter follow-up duration (5 days [IQR, 2-7] vs. 46 days [IQR, 12-132]; P = 0.02) and any complication (P < 0.001). No variable was significantly associated with postoperative complication; however, 2 variables that notably neared significance were preoperative infection of the lesion (P = 0.05) and longer surgical delay (P = 0.06).

CONCLUSIONS

Most patients born with myelomeningocele in Zambia present for first neurosurgical evaluation after 1 week of age. Preoperative infection of the lesion and postoperative complications are relatively common, and complications are a significant predictor of postoperative mortality. Further investigation into preoperative efforts to mitigate risk of postoperative complications and mortality is warranted.

Pediatric hydrocephalus outcomes in Lusaka, Zambia

OBJECTIVE

Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia.

METHODS

This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications.

RESULTS

A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001).

CONCLUSIONS

Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.

Supervision as a tool for building surgical capacity of district hospitals: the case of Zambia

INTRODUCTION

Many countries in sub-Saharan Africa have adopted task shifting of surgical responsibilities to non-physician clinicians (NPCs) as a solution to address workforce shortages. There is resistance to delegating surgical procedures to NPCs due to concerns about their surgical skills and lack of supervision systems to ensure safety and quality of care provided. This study aimed to explore the effects of a new supervision model implemented in Zambia to improve the delivery of health services by surgical NPCs working at district hospitals.

METHODS

Twenty-eight semi-structured interviews were conducted with NPCs and medical doctors at nine district hospitals and with the surgical specialists who provided in-person and remote supervision over an average period of 15 months. Data were analysed using 'top-down' and 'bottom-up' thematic coding.

RESULTS

Interviewees reported an improvement in the surgical skills and confidence of NPCs, as well as better teamwork. At the facility level, supervision led to an increase in the volume and range of surgical procedures done and helped to reduce unnecessary surgical referrals. The supervision also improved communication links by facilitating the establishment of a remote consultation network, which enabled specialists to provide real-time support to district NPCs in how to undertake particular surgical procedures and expert guidance on referral decisions. Despite these benefits, shortages of operating theatre support staff, lack of equipment and unreliable power supply impeded maximum utilisation of supervision.

CONCLUSION

This supervision model demonstrated the additional role that specialist surgeons can play, bringing their expertise to rural populations, where such surgical competence would otherwise be unobtainable. Further research is needed to establish the cost-effectiveness of the supervision model; the opportunity costs from surgical specialists being away from referral hospitals, providing supervision in districts; and the steps needed for regular district surgical supervision to become part of sustainable national programmes.

The cost of providing and scaling up surgery: a comparison of a district hospital and a referral hospital in Zambia

The lack of access to quality-assured surgery in rural parts of sub-Saharan Africa, where the numbers of trained health workers are often insufficient, presents challenges for national governments. The case for investing in scaling up surgical systems in low-resource settings is 3-fold: the potential beneficial impact on a large proportion of the global burden of disease; better access for rural populations who have the greatest unmet need; and the economic case. The economic losses from untreated surgical conditions far exceed any expenditure that would be required to scale up surgical care. We identified the resources used in delivering surgery at a rural district-level hospital and an urban based referral hospital in Zambia and calculated their cost through a combination of bottom-up costing and step-down accounting. Surgery performed at the referral hospital is ∼50% more expensive compared with the district hospital, mostly because of the higher cost of hospital stay. The low bed occupancy rates at the two hospitals suggest underutilization of the capacity, and/or missing elements of needed capacity, to conduct surgery. Nevertheless, our study confirms that scaling up district-level surgery makes sense, through bringing economies of scale, while acknowledging the need for more comprehensive assessments and costing of capacity constraints. We quantified the economies of scale under different scaling scenarios. If surgery at the district hospital was scaled up by 10, 20 or 50%, the total cost of surgery would increase proportionately less than that, i.e. by 6, 12 and 30%, respectively. If this were to lead to less demand for surgery at the referral hospital, say 10% less surgery, it would result in a reduction of 2.7% in the total cost. Although the health system as a whole would benefit, the referring hospitals would not derive the full economic benefit, unless Government increased resources for district-level surgery.

The contribution of non-physician clinicians to the provision of surgery in rural Zambia-a randomised controlled trial

BACKGROUND

The global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a 'task-shifting' solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia.

METHODS

Sixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs).

RESULTS

There was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (- 47%) (P = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (- 4.9%) and slight increase in the control arm (+ 4.8%) (P = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS (P = 0.884) and other major surgical cases (P = 0.33) at intervention hospitals between MLs and MDs.

CONCLUSION

This study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans.

TRIAL REGISTRATION

ISRCTN66099597 Registered: 07/01/2014.