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Abbas S, Chokotho L, Nyamulani N, Oliver VL. The burden of long bone fracture and health system response in Malawi: A scoping review. Injury 2024; 55:111243. [PMID: 38096746 DOI: 10.1016/j.injury.2023.111243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets. METHODS A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care. RESULTS Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources. CONCLUSIONS To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia.
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | | | - Victoria L Oliver
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
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Louw J, McCaul M, English R, Nyasulu PS, Davies J, Fourie C, Jassat J, Chu KM. Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2023; 47:3060-3069. [PMID: 37747549 PMCID: PMC10694117 DOI: 10.1007/s00268-023-07183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.
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Affiliation(s)
- Johnelize Louw
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M McCaul
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - P S Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Davies
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Fourie
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J Jassat
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - K M Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Plot 4775 Notwane Rd, Gaborone, Botswana
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Abbas A, Rice HE, Poenaru D, Samad L. Defining Feasibility as a Criterion for Essential Surgery: A Qualitative Study with Global Children's Surgery Experts. World J Surg 2023; 47:3083-3092. [PMID: 37838634 DOI: 10.1007/s00268-023-07203-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The Disease Control Priorities (DCP-3) group defines surgery as essential if it addresses a significant burden, is cost-effective, and is feasible-yet the feasibility component remains largely unexplored. The aim of this study was to develop a precise definition of feasibility for essential surgical procedures for children. METHODS Four online focus group discussions (FGDs) were organized among 19 global children's surgery providers with experience of working in low- and lower-middle-income countries (LMICs), representing 10 countries. FGDs were transcribed verbatim, and qualitative data analysis was performed. Codes, categories, themes, and subthemes were identified. RESULTS Six determinants of feasibility were identified, including: adequate human resources; adequate material resources; procedure and disease complexity; team commitment and understanding of their setting; timely access to care; and the ability to monitor and achieve good outcomes. Factors unique to feasibility of children's surgery included children's right to health and their reliance on adults for accessing safe and timely care; the need for specialist workforce; and children's unique perioperative care needs. FGD participants reported a greater need for task-sharing and shifting, creativity, and adaptability in resource-limited settings. Resource availability was seen to have a direct impact on decision-making and prioritization, e.g., saving a life versus achieving the best outcome. CONCLUSIONS The identification of a precise definition of feasibility serves as a pivotal step in identifying a list of essential surgical procedures for children, which would serve as indicators of institutional surgical capacity for this age group.
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Affiliation(s)
- Alizeh Abbas
- Center for Essential Surgical and Acute Care, Global Health Directorate, Indus Hospital and Health Network, Karachi, Pakistan.
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, 35233, USA.
| | - Henry E Rice
- Department of Surgery, Duke University, Durham, NC, USA
| | - Dan Poenaru
- Department of Pediatric Surgery, McGill University, Montreal, QC, Canada
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Jones B, Cohoe B, Brown K, Flores M, Peurrung K, Smith T, Shearer D, Zirkle L. Predictors of nonunion for transverse femoral shaft fractures treated with intramedullary nailing: a SIGN database study. OTA Int 2023; 6:e281. [PMID: 37497387 PMCID: PMC10368386 DOI: 10.1097/oi9.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 05/25/2023] [Accepted: 06/14/2023] [Indexed: 07/28/2023]
Abstract
Introduction Nonunion is a common postfracture complication resulting in decreased quality of life for patients in resource-limited settings. This study aims to determine how age, sex, injury mechanism, and surgical intervention affect the rate of nonunion in transverse femur fractures treated with a SIGN intramedullary nail (IMN). Methods A retrospective study was conducted using the SIGN online surgical database. All patients older than 16 years with simple transverse (<30 degrees), open or closed, femur fractures treated using a SIGN IMN between 2007 and 2021 were included. Our primary outcome of nonunion was measured with the modified Radiographic Union Scale for Tibial fractures (mRUST); scores ≤9 of 16 defined nonunion. The secondary outcome was squat depth. Outcomes were evaluated at follow-up appointments between 240 and 365 days postoperatively. Univariate and multivariate analysis were used for statistical comparison. Results Inclusion criteria were met for 182 patients. The overall radiographic union rate was 61.0%, and a high proportion (84.4%) of patients could squat with their hips at or below the level of their knees. Older age, retrograde approach, and fracture distraction were associated with nonunion, but sex, injury mechanism, and other surgical variables were not. Conclusion Poor reduction with fracture distraction was associated with a higher rate of nonunion. Loss of follow-up may have contributed to our overall union rate; however, we observed high rates of functional healing using the SIGN IMN. Level of evidence IV.
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Affiliation(s)
- Brett Jones
- Elson S. Floyd College of Medicine, Spokane, WA
| | - Blake Cohoe
- Elson S. Floyd College of Medicine, Spokane, WA
| | - Kelsey Brown
- Institute for Global Orthopedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Michael Flores
- Institute for Global Orthopedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | | | - Terry Smith
- SIGN Fracture Care International, Richland, WA
| | - David Shearer
- Institute for Global Orthopedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, CA
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Salam A, Wireko AA, Jiffry R, Ng JC, Patel H, Zahid MJ, Mehta A, Huang H, Abdul-Rahman T, Isik A. The impact of natural disasters on healthcare and surgical services in low- and middle-income countries. Ann Med Surg (Lond) 2023; 85:3774-3777. [PMID: 37554857 PMCID: PMC10406090 DOI: 10.1097/ms9.0000000000001041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Abdus Salam
- Department of Surgery, Khyber Teaching Hospital
| | | | - Riaz Jiffry
- Faculty of Medicine and Health Sciences, University of Putra Malaysia, Serdang, Malaysia
| | - Jyi C. Ng
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Heli Patel
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Florida, USA
| | - Muhammad J. Zahid
- Department of Surgery, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Aashna Mehta
- Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Helen Huang
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Arda Isik
- Department of General Surgery, Istanbul Medeniyet University, Istanbul, Turkey
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Krishnan A, Asadullah M, Kumar R, Amarchand R, Bhatia R, Roy A. Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 15:100222. [PMID: 37614354 PMCID: PMC10442961 DOI: 10.1016/j.lansea.2023.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 08/25/2023]
Abstract
Background Lack of timely care is a predictor of poor outcomes in acute cardiovascular emergencies including stroke. We assessed the presence of delay in seeking appropriate care among those who died due to cardiac/stroke emergencies in a community in northern India and identified the reasons and determinants of this delay. Methods We conducted a social audit among all civil-registered premature (30-69 years) deaths due to acute cardiac event or stroke in the district. The three-delays model was used to qualitatively classify the delays in care-seeking-deciding to seek care, reaching the appropriate health facility (AHF) and initiating definitive treatment. Based on the estimated time from symptom onset to reaching AHF, we classified patients as early (reached within one hour) or delayed arrivers. We used mixed-effect logistic regression with postal code as a random effect to identify determinants of delayed arrival. Findings Only 10.8% of the deceased reached an AHF within one hour. We noted level-1 delay in 38.4% (60% due to non-recognition of seriousness); level-2 delay in 20% (40% due to going to an inappropriate facility) and level-3 delay in 10.8% (57% due to lack of affordability). Patients with a monthly family income of >270US$ (aOR 0.44; 95% CI 0.21-0.93) were less and those staying farther from AHF (aOR 1.12; 95% CI 1.01-1.25 for each Km) were more likely to have delayed arrival in AHF. Interpretation A small proportion of patients with cardiac and stroke emergencies reach health facility early with delays at multiple levels. Addressing the reasons for delay could prevent these deaths. Funding : Indian Council of Medical Research, New Delhi, India.
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Affiliation(s)
- Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Md Asadullah
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ritvik Amarchand
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ambuj Roy
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Whitaker J, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard RF, Leather AJM, Davies J. Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi. BMJ Open 2023; 13:e070900. [PMID: 37263691 DOI: 10.1136/bmjopen-2022-070900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN Facilitated group process mapping workshops with summary process mapping synthesis. SETTING Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS Fifty-four healthcare workers from various cadres took part. RESULTS An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Abena S Amoah
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Health Office, Karonga, Malawi
- Department of Pathology, School of Medicine & Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Boston Munthali
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Salendo J, Ximenes J, Soares A, Guest G, Hagander L. Acute burn care and outcomes at the Hospital Nacional Guido Valadares (HNGV), Timor-Leste: A 7-year retrospective study. Medicine (Baltimore) 2022; 101:e32113. [PMID: 36550901 PMCID: PMC9771211 DOI: 10.1097/md.0000000000032113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The purpose of this study was to describe the epidemiology of patients presenting with acute burns and undergoing admission at Hospital Nacional Guido Valadares (HNGV) in Dili, Timor-Leste in the period 2013 to 2019. HNGV is the only tertiary referral hospital in Timor-Leste. This was a retrospective study involving all acute burn patients admitted to the surgical wards of HNGV from 2013 to 2019. The data was collected from patient charts and hospital medical archives. Data were reviewed and analyzed statistically in terms of age, gender, residence, cause, total body surface area (TBSA), burns depth, length of stay (LOS), and mortality. The outcomes were analyzed using logistic regression. Over the 7-year period, there were 288 acute burn patients admitted to the surgical wards of HNGV. Most patients were children (55%), male (65%) and from the capital city of Dili or surrounding areas (59%). The most common cause of burns in children was scalds and the most common cause among adults was flames. Of the admitted patients 59% had burns affecting >10% of the TBSA and 41% had full thickness burns. The median LOS was 17 days (1-143) and the average mortality for admitted burn patients in HNGV was 5.6% (annual mortality 0-17%). The odds ratio for extended LOS was 1.9 (95% confidence interval 1.1-3.2) in female compared with male patients. The odds ratio for mortality was 14.6 (95% confidence interval 2.7-80.6) in the older adults when compared with younger adults. Higher TBSA, full thickness burns, and flame burns were also significantly associated with longer LOS and higher mortality. Children and male patients were disproportionately overrepresented among patients admitted to HNGV, while female patients had longer LOS and older adults had more severe injury and a higher risk of mortality. Establishment of a national program for the prevention of burns is essential.
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Affiliation(s)
- Junius Salendo
- Institute of Tropical Medicine and International Health Charité, Universitätsmedizin Berlin, Berlin, Germany
- Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Joao Ximenes
- Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Alito Soares
- Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Glenn Guest
- Epworth Geelong Hospital and Department of Clinical and Biomedical Sciences, Deakin University, Geelong, Victoria, Australia
| | - Lars Hagander
- Department of Clinical Sciences in Lund, Pediatric Surgery, Skåne University Hospital in Lund, Faculty of Medicine, Lund University, Lund, Sweden
- * Correspondence: Lars Hagander, Department of Clinical Sciences in Lund, Pediatric Surgery, Skåne University Hospital in Lund, Faculty of Medicine, Lund University, Lund, Sweden (e-mail: )
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Nezerwa Y, Miranda E, Velin L, Shyaka I, Mukagaju F, Busomoke F, Nsanzimana JDD, Mukeshimana M, Mushimiyimana D, Mukambasabire B, Uwimana L, Ntirenganya F, Furaha C, Riviello R, Pompermaier L. Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study. J Surg Res 2022; 278:216-222. [DOI: 10.1016/j.jss.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
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A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study. World J Surg 2022; 46:1643-1659. [PMID: 35412059 PMCID: PMC9174323 DOI: 10.1007/s00268-022-06530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children's journey to surgical care. We aimed to explore children's journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania. METHODS A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann-Whitney, Kruskal-Wallis and Fisher's exact tests were used for data analysis. RESULT We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died. CONCLUSION Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children's surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.
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Hellwinkel JE, Working ZM, Certain L, García AJ, Wenke JC, Bahney CS. The intersection of fracture healing and infection: Orthopaedics research society workshop 2021. J Orthop Res 2022; 40:541-552. [PMID: 35076097 PMCID: PMC9169242 DOI: 10.1002/jor.25261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years. Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.
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Affiliation(s)
- Justin E. Hellwinkel
- Columbia University, Department of Orthopedic Surgery, 622 West 168 Street, PH 11-Center, New York, NY 10032, USA
| | - Zachary M Working
- Oregon Health & Sciences University, Department of Orthopaedic Surgery and Rehabilitation, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA
| | - Laura Certain
- University of Utah, Division of Infectious Diseases, 30 N 1900 E, 4B319 Salt Lake City, UT 84132,George E. Wahlen VA Medical Center, 500 Foothill Drive Salt Lake City, UT 84148
| | - Andrés J. García
- Georgia Institute of Technology, Woodruff School of Mechanical Engineering and Petit Institute for Bioengineering and Bioscience, 315 Ferst Dr, Atlanta, GA 30332
| | - Joseph C. Wenke
- U.S. Army Institute of Surgical Research, Department of Extremity Trauma and Regenerative Medicine, 3698 Chambers Pass Ste B, JBSA Ft. Sam, Houston, TX 78234
| | - Chelsea S. Bahney
- The Steadman Clinic & Steadman Philippon Research Institute Center for Regenerative Sports Medicine, 181 West Meadow Drive, Vail, CO 81657, USA,University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital, Orthopaedic Trauma Institute. 2550 23rd Street, Building 9, San Francisco, CA 94110, USA
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Shirley H, Wamai R. A Narrative Review of Kenya's Surgical Capacity Using the Lancet Commission on Global Surgery's Indicator Framework. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100500. [PMID: 35294388 PMCID: PMC8885340 DOI: 10.9745/ghsp-d-21-00500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/12/2022] [Indexed: 11/15/2022]
Abstract
Surgery, anesthesia, and obstetric (SAO) care is quickly being recognized for its critical role in cost-effectively improving global morbidity and mortality. Six core indicators for SAO capacity were established in 2015 by the Lancet Commission on Global Surgery (LCoGS) and include: SAO provider density, population proximity to surgery-ready facilities, annual national operative volume, a system to track perioperative mortality rate, and protection from impoverishing and catastrophic expenditures. The surgical capacity of Kenya, a lower-middle-income country, has not been evaluated using this framework. Our goal was to review published literature on surgery in Kenya to assess the country's surgical capacity and system strength. A narrative review of the relevant literature provided estimates for each LCoGS indicator. While progress has been made in expanding access to care across the country, key steps remain in the effort to provide equitable, affordable, and timely care to Kenya's population through universal health coverage. Additional investment into training SAO providers, operative infrastructure, and accessibility are recommended through a national surgery, obstetric, and anesthesia plan.
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Affiliation(s)
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, Northeastern University, College of Social Sciences and Humanities, Integrated Initiative for Global Health, Boston, MA, USA
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13
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Sund G, Huang AH, Mascha EJ, Miburo C, Machemedze S, Razafimanantsoa M, Tankombo R, Brown JA, Watts E, O'Connor Z. Delays to essential surgery at four faith based hospitals in rural Sub-Saharan Africa. ANZ J Surg 2021; 92:228-234. [PMID: 34967082 DOI: 10.1111/ans.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data regarding delays for emergency surgery in Sub-Saharan Africa is limited. We have therefore decided to undertake an evaluation of delays in patients seeking care, reaching care and receiving care for emergency surgery at four rural faith-based hospitals in this region over a 3 month period. METHODS This is a cross-sectional, multi-center, international study at four rural faith-based hospitals in Madagascar, Gabon, Cameroon and Burundi. All patients presenting at these hospitals between 10 February and 1 May 2020 for one of the three Bellwether procedures (caesarean delivery, emergency laparotomy, management of open fracture) were to be enrolled in this study. Data was collected in the form of a questionnaire administered to the patient or the patient's caregiver within 24 h of admission to the hospital. RESULTS After analysis of data for 148 patients, we found that the median [quartiles] delay in seeking care overall was 3.5 [0.5, 17.6] h, in reaching care 7.6 [2.3, 33.6] h and in receiving care 3.6 [1.7, 6.8] h. In 72% (107/148) of cases, the second delay was more than 2 h. Sixty-five percent of patients who were delayed reported that their delay was because care was sought elsewhere before arrival at one of our Bellwether-capable sites. CONCLUSIONS Our results suggest that the majority of patients needing emergency surgical care in the rural areas of Sub-Saharan Africa where our study was conducted are frequently delayed, with the largest delay being in reaching care. Further investigations into the reasons for these delays should be conducted.
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Affiliation(s)
- Gregory Sund
- Department of Anesthesia and Réanimation, Hope Africa University, Kibuye, Burundi
| | - Andrew H Huang
- Département de chirurgie, Hôpital Évangélique de Bongolo, Lébamba, Gabon.,Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Edward J Mascha
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Césarie Miburo
- Frank Odgen School of Medicine, Hope Africa University, Bujumbura, Burundi
| | - Solomon Machemedze
- Département de chirurgie, Hôpital Évangélique de Bongolo, Lébamba, Gabon
| | | | - Roger Tankombo
- Department of Surgery, Mbingo Baptist Hospital, Mbingo, Cameroon
| | - James A Brown
- Department of Surgery, Mbingo Baptist Hospital, Mbingo, Cameroon
| | - Edward Watts
- Department of Surgery, Good News Hospital, Mandritsara, Madagascar
| | - Zachary O'Connor
- Département de chirurgie, Hôpital Évangélique de Bongolo, Lébamba, Gabon
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14
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Hoh SM, Wahab MYA, Hisham AN, Guest GD, Watters DAK. Mapping timely access to emergency and essential surgical services: The Malaysian experience. ANZ J Surg 2021; 92:223-227. [PMID: 34075677 DOI: 10.1111/ans.16986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/05/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia. METHODS The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping. RESULTS There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region. CONCLUSION There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.
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Affiliation(s)
- Su Mei Hoh
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | | | | | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - David A K Watters
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
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15
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Agasaro O, Munezero G, Wong R, Hirwa A, Bekele A. Assessment of Delays in Emergency Surgical Care and Patient Postoperative Outcomes at a Referral Hospital in Northern Rwanda. World J Surg 2021; 45:1678-1685. [PMID: 33635340 DOI: 10.1007/s00268-021-06013-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical interventions are cost-effective methods to save lives and prevent disabilities. Surgical delays and access to three Bellwether procedures are key monitoring indicators for universal access to safe and affordable surgical and anesthesia care and health system performance. This study assessed the delays in receiving surgical and anesthesia care for emergency surgical patients at a district hospital in Northern Rwanda. METHODS A questionnaire was used to survey all emergency surgical patients who presented at the hospital between May and July 2020, to assess the delays in seeking (first) and reaching (second) care. In-hospital (third) delay and patient outcomes within the first 7 days postsurgery were collected by patient file auditing. Factors associated with third delay were identified through healthcare provider in-depth interviews. RESULTS A total of 106 patients were surveyed, and nine healthcare providers were interviewed. The median was less than a day for first delay, 1 day for second delay, and 16.5 h for third delay for all emergency procedures. 20% of the Bellwether procedures were performed within two hours after arriving at the hospital. Factors affecting the delays included visiting a traditional healer, district of residence, referral system, income status, as well as shortage of surgeons and specialists, surgical supplies, and operating theaters. CONCLUSION Further research to study the cause of delays within the referral system is needed. Surgical outreach, equipment, and infrastructure would help to shorten in-hospital delays. Longer-term follow-up studies on patient complications and outcomes due to delay in surgical care are needed.
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Affiliation(s)
- Orietta Agasaro
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda.
| | | | - Rex Wong
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda.,School of Public Health, Yale University, 60 College St, New Haven, CT, 06510, USA
| | | | - Abebe Bekele
- University of Global Health Equity, Kigali, PO Box 6955, Kigali, Rwanda
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16
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Foote CJ, Tornetta P, Reito A, Al-Hourani K, Schenker M, Bosse M, Coles CP, Bozzo A, Furey A, Leighton R. A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data. J Bone Joint Surg Am 2021; 103:265-273. [PMID: 33298796 DOI: 10.2106/jbjs.20.01103] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
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Affiliation(s)
| | - Paul Tornetta
- Department of Orthopedics, Boston University Medical Center, Boston, Massachusetts
| | - Aleksi Reito
- Tampere University Hospital (TAUH), Tampere, Finland
| | - Khalid Al-Hourani
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Mara Schenker
- Orthopedic Trauma Research Unit, Emory University, Atlanta, Georgia
| | - Michael Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Chad P Coles
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Andrew Furey
- Division of Orthopaedics, Memorial University, St. John's, Newfoundland, Canada
| | - Ross Leighton
- Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada
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17
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James K, Borchem I, Talo R, Aihi S, Baru H, Didilemu F, Moore EM, McLeod E, Watters DA. Universal access to safe, affordable, timely surgical and anaesthetic care in Papua New Guinea: the six global health indicators. ANZ J Surg 2020; 90:1903-1909. [PMID: 33710739 DOI: 10.1111/ans.16148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The unmet global burden of surgical disease is substantial. The Lancet Commission on Global Surgery (LCoGS) estimated that 5 billion people do not have access to safe, affordable and timely surgical care, with 80% of those without access living in low- and middle-income countries. The Milne Bay Province (pop 331 000) of Papua New Guinea, with an archipelago of islands up to 750 km from its capital, Alotau, has only one hospital capable of performing Caesarean Section, Emergency Laparotomy and managing an open fracture, the three Bellwether procedures. This paper aims to report the six Lancet Commission on Global Surgery metrics for Milne Bay Province. METHODS The study was conducted between January and August 2019. Bellwether access was investigated by a prospective study on 115 patients presenting to hospital. The surgical, anaesthesia and obstetric (SAO) workforce, surgical volume and perioperative mortality rate, were calculated for 2012-2018 from hospital records and operation registers. Financial risk metrics were calculated by surveying 50 patients at discharge from hospital. RESULTS Bellwether access: Only 27.8% (n = 32) of the study population (n = 115) experienced less than 2-hours second delay (journey time to hospital). The average SAO provider density was 1.8 per 100 000 population. There were 606 procedures performed per 100 000 with a mean annual perioperative mortality rate of 0.3%. Catastrophic expenditure is a risk for 29% of the population. CONCLUSION Milne Bay Province can perform surgery safely, but there is limited access to timely surgical care when needed with a significant proportion put at financial risk by requiring it.
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Affiliation(s)
- Kennedy James
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Isaiah Borchem
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Rodney Talo
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Sonia Aihi
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Helai Baru
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Fiona Didilemu
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Eileen M Moore
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - Elizabeth McLeod
- Paediatric and Neonatal Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - David A Watters
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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18
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Watters DA, Tangi V, Guest GD, McCaig E, Maoate K. Advocacy for global surgery: a Pacific perspective. ANZ J Surg 2020; 90:2084-2089. [DOI: 10.1111/ans.15972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David A. Watters
- Department of Surgery Deakin University and Barwon Health Geelong Victoria Australia
- RACS Global Health Royal Australasian College of Surgeons Melbourne Victoria Australia
| | - Viliami Tangi
- Department of Surgery Ministry of Health Nuku'alofa Tonga
| | - Glenn D. Guest
- Department of Surgery Deakin University and Barwon Health Geelong Victoria Australia
- RACS Global Health Royal Australasian College of Surgeons Melbourne Victoria Australia
- Department of Surgery Epworth Geelong Geelong Victoria Australia
| | - Eddie McCaig
- Department of Surgery Fiji National University Suva Fiji
| | - Kiki Maoate
- Department of Surgery Epworth Geelong Geelong Victoria Australia
- Department of Surgery University of Otago Christchurch New Zealand
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19
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Peck GL. Interfacility transfer: an indicator of delay in fracture care. THE LANCET GLOBAL HEALTH 2020; 8:e623-e624. [DOI: 10.1016/s2214-109x(20)30088-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022] Open
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20
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Fordyce A, Vorias B, Taranto L, Soares A, Watters D, Saunders C. Breast disease in Timor-Leste. ANZ J Surg 2020; 90:1920-1924. [PMID: 32062871 DOI: 10.1111/ans.15720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgically treatable conditions are well documented in high-income countries. There is a gap in epidemiological understanding of breast pathology in many developing countries, Timor-Leste among them. This study was conducted to determine the burden of breast disease and to inform public health measures to address early detection, diagnosis and management. METHODS A retrospective quantitative case-control study was conducted at Guido Valadares National Hospital in Dili. Patients were included if they attended surgical outpatients or had a pathology specimen recorded between 1 September 2016 and 1 September 2017. RESULTS There were 444 female patients with a clinical diagnosis of breast disease over the 12-month period. The average age was 33.7 years. There were 188 (42.3% of total sample) cases of fibroadenoma and 122 (27.4% of total sample) diagnoses consistent with non-specific lumps. Of the 116 female patients presenting to Guido Valadares National Hospital who had a biopsy, 62.6% were malignant or hyperplastic in nature, and 86% of those with a malignant biopsy had clinically locally advanced disease. CONCLUSION Breast conditions including cancer in Timor-Leste are relatively common and occur in young women in the prime of their lives (37 years of age). Developing a national cancer registry and funding directed towards improving early presentation and good clinical care of breast cancer patients will be critical for reducing early morbidity and mortality and improving other patient outcomes including income loss, gender health inequality and the intergenerational effects of early parental death.
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Affiliation(s)
- Andrew Fordyce
- Department of General Surgery, Alfred Health, Melbourne, Victoria, Australia.,Global Health Division, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Blake Vorias
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Lucas Taranto
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Alito Soares
- Department of Surgery, Guido Valadares National Hospital, Dili, Timor-Leste
| | - David Watters
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Christobel Saunders
- School of Surgery and Pathology, The University of Western Australia, Perth, Western Australia, Australia.,Department of Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Surgery, St John of God Hospital, Perth, Western Australia, Australia
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