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The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors. J Trauma Acute Care Surg 2024; 96:893-900. [PMID: 38227675 DOI: 10.1097/ta.0000000000004247] [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] [Indexed: 01/18/2024]
Abstract
BACKGROUND Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes. METHODS Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated. RESULTS Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores. CONCLUSION Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Surgical capacity is disaster preparedness: A scoping review of how surgery and anesthesiology departments responded to COVID-19. Am J Disaster Med 2024; 19:119-130. [PMID: 38698510 DOI: 10.5055/ajdm.0466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
OBJECTIVE This study evaluated how surgical and anesthesiology departments adapted their resources in response to the coronavirus disease 2019 (COVID-19) pandemic. DESIGN This scoping review used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol, with Covidence as a screening tool. An initial search of PubMed, Embase, Web of Science, Global Index Medicus, and Cochrane Systematic Reviews returned 6,131 results in October 2021. After exclusion of duplicates and abstract screening, 415 articles were included. After full-text screening, 108 articles remained. RESULTS Most commonly, studies were retrospective in nature (47.22 percent), with data from a single institution (60.19 percent). Nearly all studies occurred in high-income countries (HICs), 78.70 percent, with no articles from low-income countries. The reported responses to the COVID-19 pandemic involving surgical departments were grouped into seven categories, with multiple responses reported in some articles for a total of 192 responses. The most frequently reported responses were changes to surgical department staffing (29.17 percent) and task-shifting or task-sharing of personnel (25.52 percent). CONCLUSION Our review reflects the mechanisms by which hospital surgical systems responded to the initial stress of the COVID-19 pandemic and reinforced the many changes to hospital policy that occurred in the pandemic. Healthcare systems with robust surgical systems were better able to cope with the initial stress of the COVID-19 pandemic. The well-resourced health systems of HICs reported rapid and dynamic changes by providers to assist in and ultimately improve the care of patients during the pandemic. Surgical system strengthening will allow health systems to be more resilient and prepared for the next disaster.
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Quantifying Pediatric Gun Violence by Location, Time of Day, and Day of Week. J Pediatr Surg 2024; 59:1003-1008. [PMID: 38030529 DOI: 10.1016/j.jpedsurg.2023.11.002] [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: 07/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Firearm injuries are the leading cause of pediatric deaths. The objective of this study was to describe the location and timing of pediatric firearm injuries and to determine the proportion of these injuries that occur within schools in the United States. METHODS In this retrospective cohort study, we used national emergency medical services (EMS) data from 2019 to evaluate dispatches to firearm injuries involving school-aged children (age 5-18). We extracted incident location type, patient demographics, number of patients on scene, and injury intent. RESULTS We identified 4764 EMS dispatches for firearm injuries in school-aged children during 2019. Assault was the most common cause of injury (53.9 %), followed by unintentional shootings (12.1 %) and self-inflicted injuries (6.1 %). Most incidents involved a single patient (91.4 %). Private residence (51.5 %) was the most common location, followed by street/road (23.8 %). 81 firearm injuries (1.7 %) occurred in a school. Private residence was the most common location of injury across all injury intents. During school hours, most firearm injuries occurred in a private residence (51.6 %) or on a street/road (19.9 %). A total of 63 dispatches (1.3 %) were considered a mass casualty incident, of which 9 (14 %) occurred in a school. CONCLUSIONS Regardless of injury intent or time of day, the most common location for pediatric firearm injuries was a private home. Firearm injuries within schools were far less frequent. In designing prevention strategies, our data calls for renewed focus on preventing children from accessing firearms in the home and instituting comprehensive, community-based after school programs. TYPE OF STUDY Retrospective cohort. LEVEL OF EVIDENCE III.
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The Global Macroeconomic Burden of Burn Injuries. Plast Reconstr Surg 2024; 153:743-752. [PMID: 37093034 DOI: 10.1097/prs.0000000000010595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution. METHODS Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach. RESULTS There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs) of Oceania (0.24%; 95% UI, 0.09% to 0.42%) and Eastern Europe (0.24%; 95% UI, 0.19% to 0.30%) compared with high-income country regions such as Western Europe (0.06%; 95% UI, 0.04% to 0.09%). Mortality-incidence ratios were highest in LMIC regions, highlighting a lack of treatment access, with southern sub-Saharan Africa reporting a mortality-incidence ratio of 40.1 per 1000 people compared with 1.9 for Australasia. CONCLUSIONS Burden of disease and resulting economic losses because of burn injuries are substantial worldwide and are disproportionately higher in LMICs. Possible effective solutions include targeted education, advocacy, and legislation to decrease incidence and investing in existing burn centers to improve treatment access.
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Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors. Am J Surg 2024:S0002-9610(24)00100-4. [PMID: 38413351 DOI: 10.1016/j.amjsurg.2024.02.013] [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: 12/11/2023] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury. METHODS Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ≥ 3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors. RESULTS 2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR = 1.57; 95% CI = 1.21, 2.03), and worse SF-12 mental (mean Δ = -1.43; 95% CI = -2.79, -0.09) and physical scores (mean Δ = -2.61; 95% CI = -3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group. CONCLUSIONS Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.
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Multicenter evaluation of financial toxicity and long-term health outcomes after injury. J Trauma Acute Care Surg 2024; 96:54-61. [PMID: 37867247 DOI: 10.1097/ta.0000000000004161] [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] [Indexed: 10/24/2023]
Abstract
BACKGROUND Despite the growing awareness of the negative financial impact of traumatic injury on patients' lives, the association between financial toxicity and long-term health-related quality of life (hrQoL) among trauma survivors remains poorly understood. METHODS Patients from nine trauma centers participating in a statewide trauma quality collaborative had responses from longitudinal survey data linked to inpatient trauma registry data. Financial toxicity was defined based on patient-reported survey responses regarding medical debt, work or income loss, nonmedical financial strain, and forgone care due to costs. A financial toxicity score ranging from 0 to 4 was calculated. Health-related quality of life was assessed using the EuroQol 5 Domain tool. Multivariable regression models evaluated the association between financial toxicity and hrQoL outcomes while adjusting for patient demographics, injury severity and inpatient treatment intensity, and health systems variables. RESULTS Among the 403 patients providing 510 completed surveys, rates of individual financial toxicity elements ranged from 21% to 46%, with 65% of patients experiencing at least one element of financial toxicity. Patients with any financial toxicity had worse summary measures of hrQoL and higher rates of problems in all five EuroQol 5 Domain domains ( p < 0.05 for all). Younger age, lower household income, lack of insurance, more comorbidities, discharge to a facility, and air ambulance transportation were independently associated with higher odds of financial toxicity ( p < 0.05 for all). Injury traits and inpatient treatment intensity were not independently associated with financial toxicity. CONCLUSION A majority of trauma survivors in this study experienced some level of financial toxicity, which was independently associated with worse risk-adjusted health outcomes across all hrQoL measures. Risk factors for financial toxicity are not related to injury severity or treatment intensity but rather to sociodemographic variables and measures of prehospital and posthospital health care resource utilization. Targeted interventions and policies are needed to address financial toxicity and ensure optimal recovery for trauma survivors. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Correction: Academic global surgical competencies: A modified Delphi consensus study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002414. [PMID: 37708095 PMCID: PMC10501557 DOI: 10.1371/journal.pgph.0002414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0002102.].
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Developing a Surgical Simulation Curriculum for the Rwandan Context. JOURNAL OF SURGICAL EDUCATION 2023; 80:1268-1276. [PMID: 37482530 DOI: 10.1016/j.jsurg.2023.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/13/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda. DESIGN This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students. SETTING University of Global Health Equity, a new medical school located in Butaro, Rwanda. PARTICIPANTS Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship. RESULTS The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options. CONCLUSIONS Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.
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Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda. World J Surg 2023; 47:2169-2177. [PMID: 37156884 DOI: 10.1007/s00268-023-07038-w] [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: 04/15/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience. METHODS An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys. RESULTS Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast. CONCLUSIONS The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.
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Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis. LANCET REGIONAL HEALTH. AMERICAS 2023; 24:100556. [PMID: 37521438 PMCID: PMC10372900 DOI: 10.1016/j.lana.2023.100556] [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: 02/15/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023]
Abstract
Background Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors. Methods By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach. Findings We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model. Interpretation Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico. Funding None.
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Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference. Cureus 2023; 15:e43625. [PMID: 37600431 PMCID: PMC10433784 DOI: 10.7759/cureus.43625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/22/2023] Open
Abstract
Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.
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Academic global surgical competencies: A modified Delphi consensus study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002102. [PMID: 37450426 PMCID: PMC10348592 DOI: 10.1371/journal.pgph.0002102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.
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2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing after outpatient breast surgery: Time for a streamlined approach?07. Trends in graduate degree types and research output for Canadian academic general surgeons08. Would you prefer to undergo breast-conserving therapy or a mastectomy for early breast cancer? Comparison of perceptions of general and plastic surgeons09. Lack of representation of women and BIPOC individuals in Canadian academic surgery10. Medical student interest and perspectives on pursuing surgical careers: a multicentre survey evaluating 5-year trends11. Difficult cholecystectomy with cholecystogastric fistula12. Surviving nonsurvivable injuries: patients who elude the “lethal” Abbreviated Injury Scale (AIS) score of six13. Gunshot wounds sustained during legal intervention v. those inflicted by civilians: a comparative analysis14. The impact of delayed time to first head CT on functional outcomes after blunt head trauma with moderately depressed GCS15. Contemporary utility of diagnostic peritoneal aspiration in trauma16. Impact of delayed time to first head CT in traumatic brain injury17. Radiologic predictors of in-hospital mortality after traumatic craniocervical dissociation18. Measurement properties of a patient-reported instrument to evaluate functional status after major surgery19. The safety of venous thromboembolism chemoprophylaxis use in endoscopic retrograde cholangiopancreatography20. Characterizing Canadian rural surgeons: trends over time and 10-year replacement needs21. Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial22. Evaluating the accuracy and design of visual backgrounds in academic surgical journals23. Defining rural surgery in Canada24. Validity of video-based general and procedure-specific self-assessment tools for surgical trainees in laparoscopic cholecystectomy25. Examining the equity and diversity characteristics of academic general surgeons in Canada26. Video-based coaching for surgical residents: a systematic review and meta-analysis27. Very-low-energy diets prior to nonbariatric surgery: a systematic review and meta-analysis28. Factors associated with resident research success: a descriptive analysis of Canadian general surgery trainees29. Global surgery pilot curriculum in Canadian undergraduate medical education: a novel approach30. How useful is ultrasound in predicting surgical findings of “mild cholecystitis”?31. Implementing a colorectal surgery “virtual hospital”: description of a novel outpatient care pathway to advance surgical care32. Trends in training and workforce planning for Canadian pediatric surgeons: a 10-year model33. Patient perspectives on intraoperative blood transfusion: results of semistructured interviews with perioperative patients34. Understanding intraoperative transfusion decision-making variability: a qualitative study using the Theoretical Domains Framework35. Effectiveness of preoperative oscillating positive expiratory pressure (OPEP) therapy in reduction of postoperative respiratory morbidity in patients undergoing surgery: a systematic review37. Accuracy of point-of-care testing devices for hemoglobin in the operating room: a systematic review and meta-analysis38. Opioid-free analgesia after outpatient general surgery: a qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial39. The impact of the COVID-19 pandemic on general surgery residency: an analysis of operative volumes by residents at a Canadian general surgery residency program40. Postoperative care protocols for elderly emergency surgical patients: a quality improvement initiative42. Adverse events following robotic compared to laparoscopic and open surgery: a population-based analysis43. Is accrual higher for patients randomized to pragmatic v. exploratory randomized clinical trials? A systematic review and meta-analysis44. Effect of preoperative proton-pump inhibitor use on postoperative infectious and renal complications after elective general surgery45. The early burden of COVID-19 in emergency general surgery care across Canada46. Laparoscopic subtotal cholecystectomy for the difficult gallbladder: evolution of technique at a single teaching hospital and retrospective review47. The demand for emergency general surgery in Canada: a public health crisis48. Attitudes of Canadian general surgery staff and residents toward point-of-care ultrasound49. Psychological impact of COVID-19 on Canadian surgical residents50. Validation of an artificial intelligence platform for the guidance of safe laparoscopic cholecystectomy51. Predictors of recurrent appendicitis after nonoperative management: a prospective cohort study52. The effect of the first wave of the COVID-19 pandemic on colorectal and hepatobiliary oncologic outcomes at a tertiary care centre53. Trends in training and workforce representation for Canadian general surgeons working in critical care: a descriptive study54. White presentation: teaching safe opioid prescription and opioid use disorder management in Canadian universities56. How bad is really bad, eh? Impact of the first wave of the COVID-19 pandemic on residents’ operative volume: the experience of a Canadian general surgery program57. Surgeon-specific encounters within a multidisciplinary care pathway: Is there a role for shared care models in surgery?59. A pan-Canadian analysis of approach to treatment for acute appendicitis60. Appendix neoplasm stratified by age: understanding the best treatment for appendicitis61. Predicting acute cholecystitis on final pathology to prioritize surgical urgency: an evaluation of the Tokyo criteria and development of a novel predictive score62. Obesity is an independent predictor of acute renal failure after surgery64. Validation of a clinical decision-making assessment tool in general surgery65. Moral distress in the provision of palliative care delivery for surgical patients in British Columbia: lessons learned from the perspectives of general surgeons66. Delays in presentation and severity of illness predict adverse surgical outcomes among patients transferred from rural Indigenous communities for acute care surgery67. Remote video-based suturing education with smartphones (REVISE): a randomized controlled trial68. Modified Delphi consensus on appropriate use of laboratory investigations in acute care surgery patients72. Impacts of inpatient food at a tertiary care centre on patient satisfaction, nutrition and planetary health73. Racial disparities in health outcomes for oncological surgery in Canada75. Risk of recurrent laryngeal nerve injury from thyroidectomy is lower when intraoperative nerve monitoring (IONM) is used: an analysis of 17 688 patients from the NSQIP database01. The impact of the COVID-19 pandemic on non-smallcell lung cancer pathologic stage and presentation02. Screening criteria evaluation for expansion in pulmonary neoplasias (screen)03. Robotic-assisted lobectomy for early-stage lung cancer provides better patient-reported quality of life than video-assisted lobectomy: early results of the RAVAL trial04. Breathe Anew: designing and testing the feasibility of a novel intervention for lung cancer survivorship05. Learning objectives for thoracic surgery: developing a national standard for undergraduate medical education06. Plasma cell-free DNA as a point-of-care well-being biomarker for early-stage non-small-cell lung cancer patients07. Sarcopenia determined by skeletal muscle index predicts overall survival, disease-free survival and postoperative complications in resectable esophageal cancer: a systematic review and meta-analysis08. The short- and long-term effects of open v. minimally invasive thymectomy in myasthenia gravis patients: a systematic review and meta-analysis09. Optimizing opioid prescribing practices following minimally invasive lung resections through a structured quality improvement process10. Effects of virtual postoperative postdischarge care in patients undergoing lung resection during the COVID-19 pandemic11. Initiating Ethiopia’s first minimally invasive surgery program: a novel approach for collaborations in global surgical education12. Patient outcomes following salvage lung cancer surgery after definitive chemotherapy or radiation13. Replacing chest X-rays after chest tube removal with clinical assessment in postoperative thoracic surgery patients14. Updating the practice of thoracic surgery in Canada: a survey of the Canadian Association of Thoracic Surgeons15. The impact of COVID-19 on the diagnosis and treatment of lung cancer16. Development of a prediction model for survival time in esophageal cancer patients treated with resection17. The development and validation of a mixed reality thoracic surgical anatomy atlas18. Routine placement of feeding tubes should be avoided in esophageal cancer patients undergoing surgery19. Nodal count is no different during robotic segmentectomy compared with robotic lobectomy20. Point-of-care ultrasound-guided percutaneous biopsy of solid masses in the thoracic outpatient clinic: a safe, high-yield procedure to accelerate tissue diagnosis for patients with advanced thoracic malignancy21. Sarcopenia and modified frailty index are not associated with adverse outcomes after esophagectomy for esophageal cancer: a retrospective cohort study22. Near-infrared-guided segmental resection for lung cancer: an analysis of the learning curve23. Routine use of feeding jejunostomy tubes in patients undergoing esophagectomy for esophageal malignancy is safe and associated with low complication rates01. Ghost ileostomy versus loop ileostomy following total mesorectal excision for rectal cancer: a systematic review and meta-analysis02. Analysis of 100 consecutive colorectal cancers presenting at a Canadian tertiary care centre: delayed diagnosis and advanced disease03. Clinical delays and comparative outcomes in younger and older adults with colorectal cancer: a systematic review04. Recurrence rates of rectal cancer after transanal total mesorectal excision (taTME): a systematic review and meta-analysis05. Transanal total mesorectal excision for abdominoperineal resection (taTME-APR) is associated with poor oncological outcomes in rectal cancer patients: a word of caution from a multicentric Canadian cohort study06. Association between survival and receipt of recommended and timely treatment in locally advanced rectal cancer: a population-based study07. Trends and the impact of incomplete preoperative staging in rectal cancer08. Postoperative outcomes after elective colorectal surgery in patients with cirrhosis09. Bowel stimulation before loop ileostomy closure to reduce postoperative ileus: a multicentre, single-blinded, randomized controlled trial10. Recurrence following perineal rectosigmoidectomy ( Altemeier) with levatorplasty: a systematic review and meta-analysis11. Nonmodifiable risk factors and receipt of surveillance investigations following treatment of rectal cancer12. Safety and effectiveness of endoscopic full-thickness resection for the management of colorectal lesions: a systematic review and meta-analysis13. Impact of preoperative carbohydrate loading before colectomy: a systematic review and meta-analysis of randomized controlled trials14. Statin therapy in patients undergoing short-course neoadjuvant radiotherapy for rectal cancer15. Feasibility of targeted lymphadenectomy during complete mesocolic excision for colon cancer using indocyanine green immunofluorescence lymphatic mapping16. Feasibility of expanding an ambulatory colectomy protocol: a retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway17. Impact of rectal cancer on bowel dysfunction before treatment and its relationship with post-treatment function18. Canadian cost–utility analysis of artificial-intelligence-assisted colonoscopy for adenoma detection in fecal immunochemical-based colorectal cancer screening19. A comparison of outcomes following intracorporeal and extracorporeal anastomotic techniques in laparoscopic right colectomies20. Assessment of metabolic signatures using desorption electrospray ionization mass spectrometry (DESI) and rapid evaporative ionization mass spectrometry (REIMS) of rectal cancer samples to assist in determining treatment response21. The association between hospital characteristics and minimally invasive rectal cancer surgery: a population-based study22. Cancer centre level designation and the impact on treatment and outcomes in those with rectal cancer: a population-based study23. Oncological outcomes after colorectal cancer in patients with liver cirrhosis: a systematic review and meta-analysis24. Optimal preoperative nutrition for penetrating Crohn disease: a systematic review and meta-analysis25. Lymph node ratio as a predictor of survival for colon cancer: a systematic review and meta-analysis26. Barriers and facilitators for use of new recommendations for optimal endoscopic localization of colorectal neoplasms according to gastroenterologists and surgeons27. Emergency colorectal surgery in patients with cirrhosis: a population-based descriptive study28. Local recurrence rates and associated risk factors after transanal endoscopic microsurgery for benign polyps and adenocarcinomas29. Bowel dysfunction impacts mental health after restorative proctectomy for rectal cancer30. Evolution of psychological morbidity following restorative proctectomy for rectal cancer: a systematic review and meta-analysis31. Frailty predicts LARS and quality of life in rectal cancer survivors after restorative proctectomy32. Low anterior resection syndrome in a reference North American population: prevalence and predictive factors33. The evolution of enhanced recovery: same day discharge after laparoscopic colectomy34. Effect of ERAS protocols on length of stay after colorectal surgery: an interrupted time series analysis35. Practice patterns and outcomes in individuals with cirrhosis and colorectal cancer: a population-based study36. Understanding the impact of bowel function on quality of life after rectal cancer surgery37. Right-sided colectomies for diverticulitis have worse outcomes compared with left-sided colectomies38. Symptom burden and time from symptom onset to cancer diagnosis in patients with early-onset colorectal cancer39. The impact of access to robotic rectal surgery at a tertiary care centre: a Canadian perspective40. Management of rectal neuroendocrine tumours by transanal endoscopic microsurgery41. The gut microbiota modulates colorectal anastomotic healing in patients undergoing surgery for colorectal cancer42. Is there added risk of complications for concomitant procedures during an ileocolic resection for Crohn disease?43. Cost of stoma-related hospital readmissions for rectal cancer patients following restorative proctectomy with a diverting loop ileostomy: a nationwide readmissions database analysis44. Older age associated with quality of rectal cancer care: an ACS-NSQIP database study45. Outcomes of patients undergoing elective bowel resection before and after implementation of an anemia screening and treatment program47. Loop ileostomy closure as a 23-hour stay procedure: a randomized controlled trial48. Extended duration perioperative thromboprophylaxis with low-molecular-weight heparin to improve disease-free survival following surgical resection of colorectal cancer: a multicentre randomized controlled trial (PERIOP-01 Trial)49. Three-stage versus modified 2-stage ileal pouch anal anastomosis: perioperative outcomes, function and quality of life50. Compliance with extended venous thromboembolism prophylaxis in rectal cancer51. Extended-duration venous thromboembolism prophylaxis after diversion in rectal cancer52. Financial and occupational impact of low anterior resection syndrome: a qualitative study53. Nonoperative management for rectal cancer: patient perspectives54. Trends in ileostomy-related emergency department visits for rectal cancer patients55. Long-term implications of treatment of fecal incontinence: a single Canadian centre’s retrospective cohort study: a 17-year follow-up56. Externally benchmarking colorectal resection outcomes in our province against the ACS NSQIP risk calculator: identifying opportunities for improvement57. Externally benchmarking our provincial colectomy outcomes against the ACS NSQIP using the Codman Score: to identify possible opportunities for improvement of outcomes58. Rural v. urban documentation of recommended practices for optimal endoscopic colorectal lesion localization01. Incidence of in-hospital opioid use and pain after inguinal hernia repair02. Ventral hernia repair following liver transplantation: outcome of repair techniques and risk factors for recurrence01. Impact of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834 647 patients02. Patient selection and 30-day outcomes of SADI-S compared to RYGB: a retrospective cohort study of 47 375 patients03. New persistent opioid use following bariatric surgery: a systematic review and pooled proportion meta-analysis04. Bariatric surgery should be offered to active-duty military personnel: a retrospective study of the Canadian Armed Forces experience05. Opioid prescribing practices and use following bariatric surgery: a systematic review and pooled summary of data06. Sacred sharing circles: urban Indigenous Manitobans’ experiences with bariatric surgery07. Gastrogastric hernia after laparoscopic gastric great curve plication: a video presentation08. Characterization of comorbidities predictive of bariatric surgery09. Efficacy of preoperative high-dose liraglutide in patients with superobesity10. The effect of linear stapled gastrojejunostomy size in Roux-en-Y gastric bypass11. Fragility of statistically significant outcomes in randomized trials comparing bariatric surgeries12. Weight loss outcomes for patients undergoing conversion to Roux-en-Y gastric bypass after sleeve gastrectomy13. Are long waiting lists for bariatric surgery detrimental to patients? A single-centre experience14. Does upper gastrointestinal swallow study after bariatric surgery lead to earlier detection of leak?15. Pharmaceutical utilization before and after bariatric surgery16. Same-day discharge Roux-en-Y gastric bypass at a Canadian bariatric centre: pathway implementation and early experiences17. Safety and efficiency of performing primary bariatric surgery at an ambulatory site of a tertiary care hospital: a 5-year experience18. Impact of psychiatric diagnosis on weight loss outcomes 3 years after bariatric surgery19. Ursodeoxycholic acid (UDCA) for prevention of gallstone disease after laparoscopic sleeve gastrectomy (LSG): an Atlantic Canada perspective20. Fecal microbial transplantation and fibre supplementation in patients with severe obesity and metabolic syndrome: a randomized double-blind, placebo-controlled phase 2 trial01. Incidence, timing and outcomes of venous thromboembolism in patients undergoing surgery for esophagogastric cancer: a population-based cohort study04. Omission of axillary staging and survival in elderly women with early-stage breast cancer: a population-based cohort study05. Patients’ experiences receiving cancer surgery during the COVID-19 pandemic: a qualitative study06. Cancer surgery outcomes are better at high-volume centres07. Attitudes of Canadian colorectal cancer care providers toward liver transplantation for colorectal liver metastases: a national survey08. Quality of narrative central and lateral neck dissection reports for thyroid cancer treatment suggests need for a national standardized synoptic operative template09. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications and technique10. Temporal trends in lymph node assessment as a quality indicator in colorectal cancer patients treated at a high-volume Canadian centre11. Molecular landscape of early-stage breast cancer with nodal metastasis12. Beta testing of a risk-stratified patient decision aid to facilitate shared decision making for postoperative extended thromboprophylaxis in patients undergoing major abdominal surgery for cancer13. Breast reconstruction use and impact on oncologic outcomes among inflammatory breast cancer patients: a systematic review14. Association between patient-reported symptoms and health care resource utilization: a first step to develop patient-centred value measures in cancer care15. Complications after colorectal liver metastases resection in Newfoundland and Labrador16. Why do patients with nonmetastatic primary retroperitoneal sarcoma not undergo resection?17. Loss of FAM46Cexpression predicts inferior postresection survival and induces ion channelopathy in gastric adenocarcinoma18. Liver-directed therapy of neuroendocrine liver metastases19. Neoadjuvant pembrolizumab use in microsatellite instability high (MSI-H) rectal cancer: benefits of its use in lynch syndrome20. MOLLI for excision of nonpalpable breast lesions: a case series22. Patients awaiting mastectomy report increased depression, anxiety, and decreased quality of life compared with patients awaiting lumpectomy for treatment of breast cancer23. Is microscopic margin status important in retroperitoneal sarcoma (RPS) resection? A systematic review and meta-analysis24. Absence of benefit of routine surveillance in very-low-risk and low-risk gastric gastrointestinal stromal tumors25. Effect of intraoperative in-room specimen radiography on margin status in breast-conserving surgery26. Active surveillance for DCIS of the breast: qualitative interviews with patients and physicians01 Outcomes following extrahepatic and intraportal pancreatic islet transplantation: a comparative cohort study02. Cholang-funga-gitis03. Evaluating the effect of a low-calorie prehepatectomy diet on perioperative outcomes: a systematic review and meta-analysis04. Toxicity profiles of systemic therapy for advanced hepatocellular carcinoma: a systematic review to guide neoadjuvant trials05. Should cell salvage be used in liver resection and transplantation? A systematic review and meta-analysis06. The association between surgeon and hospital variation in use of laparoscopic liver resection and short-term outcomes07. Systematic review and meta-analysis of prognostic factors for early recurrence in intrahepatic cholangiocarcinoma after curative-intent resection08. Impact of neoadjuvant chemotherapy on postoperative outcomes of patients undergoing hepatectomy for intrahepatic cholangiocarcinoma: ACS-NSQIP propensity-matched analysis09. The impact of prophylactic negative pressure wound therapy on surgical site infections in pancreatic resection: a systematic review and meta-analysis10. Does hepatic pedicle clamping increase the risk of colonic anastomotic leak after combined hepatectomy and colectomy? Analysis of the ACS NSQIP database11. Development of a culture process to grow a full-liver tissue substitute12. Liver transplantation for fibrolamellar hepatocellular carcinoma: an analysis of the European Liver Transplant Registry13. Arming beneficial viruses to treat pancreatic cancer14. Hepaticoduodenostomy versus hepaticojenunostomy for biliary reconstruction: a retrospective review of a single-centre experience15. Feasibility and safety of a “shared care” model in complex hepatopancreatobiliary surgery: a 5-year analysis of pancreaticoduodenectomy16. Laparoscopic v. open pancreaticoduodenectomy: initial institutional experience and NSQIP-matched analysis17. Laparoscopic spleen-preserving distal pancreatectomy: Why not do a Warshaw?18. The impact of COVID-19 on pancreaticoduodenectomy outcomes in a high-volume hepatopancreatobiliary centre19. Transitioning from open to minimally invasive pancreaticoduodenectomy: the learning curve factor in an academic centre20. Closed-incision negative-pressure wound therapy following pancreaticoduodenectomy for prevention of surgical site infections in high-risk patients21. Robotic Appleby procedure for recurrent pancreatic cancer22. The influence of viral hepatitis status on posthepatectomy complications in patients with hepatocellular carcinoma: a NSQIP analysis. Can J Surg 2022. [DOI: 10.1503/cjs.014322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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Shifting global surgery's center of gravity. Surgery 2022; 172:1029-1030. [PMID: 35715233 DOI: 10.1016/j.surg.2022.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/18/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
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Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Insult to injury: National analysis of return to work and financial outcomes of trauma patients. J Trauma Acute Care Surg 2021; 91:121-129. [PMID: 34144560 DOI: 10.1097/ta.0000000000003135] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While much of trauma care is rightly focused on improving inpatient survival, the ultimate goal of recovery is to help patients return to their daily lives after injury. Although the overwhelming majority of trauma patients in the United States survive to hospital discharge, little is known nationally regarding the postdischarge economic burden of injuries among trauma survivors. METHODS We used the National Health Interview Survey from 2008 to 2017 to identify working-age trauma patients, aged 18 to 64 years, who sustained injuries requiring hospitalization. We used propensity score matching to identify noninjured respondents. Our primary outcome measure was postinjury return to work among trauma patients. Our secondary outcomes included measures of food insecurity, medical debt, accessibility and affordability of health care, and disability. RESULTS A nationally weighted sample of 319,580 working-age trauma patients were identified. Of these patients, 51.7% were employed at the time of injury, and 58.9% of them had returned to work at the time of interview, at a median of 47 days postdischarge. Higher rates of returning to work were associated with shorter length of hospital stay, higher education level, and private health insurance. Injury was associated with food insecurity at an adjusted odds ratio (aOR) of 1.8 (95% confidence interval, 1.40-2.37), with difficulty affording health care at aOR of 1.6 (1.00-2.47), with medical debt at aOR of 2.6 (2.11-3.20), and with foregoing care due to cost at aOR of 2.0 (1.52-2.63). Working-age trauma patients had disability at an aOR of 17.6 (12.93-24.05). CONCLUSION The postdischarge burden of injury among working-age US trauma survivors is profound-patients report significant limitations in employment, financial security, disability, and functional independence. A better understanding of the long-term impact of injury is necessary to design the interventions needed to optimize postinjury recovery so that trauma survivors can lead productive and fulfilling lives after injury. LEVEL OF EVIDENCE Economic & Value-Based Evaluations, level II; Prognostic, level II.
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The "Tick Tock" Sign: An Uncommon Physical Examination Finding for in Situ Impaled Cardiac Injuries. J Emerg Med 2020; 59:e247-e249. [PMID: 32917444 DOI: 10.1016/j.jemermed.2020.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
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Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda. J Pediatr Surg 2019; 54:838-844. [PMID: 30153942 DOI: 10.1016/j.jpedsurg.2018.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND/PURPOSE Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition. METHODS This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016. RESULTS 78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%. CONCLUSION The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources. LEVEL OF EVIDENCE III.
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Development of a Novel Global Surgery Course for Medical Schools. JOURNAL OF SURGICAL EDUCATION 2019; 76:469-479. [PMID: 30185383 DOI: 10.1016/j.jsurg.2018.07.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/16/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE We endeavored to create a comprehensive course in global surgery involving multinational exchange. DESIGN The course involved 2 weeks of didactics, 2 weeks of clinical rotations in a low-resource setting and 1 week for a capstone project. We evaluated our success through knowledge tests, surveys of the students, and surveys of our Zimbabwean hosts. SETTING The didactic portions were held in Sweden, and the clinical portion was primarily in Harare with hospitals affiliated with the University of Zimbabwe. PARTICIPANTS Final year medical students from Lund University in Sweden, Harvard Medical School in the USA and the University of Zimbabwe all participated in didactics in Sweden. The Swedish and American students then traveled to Zimbabwe for clinical work. The Zimbabwean students remained in Sweden for a clinical experience. RESULTS The course has been taught for 3 consecutive years and is an established part of the curriculum at Lund University, with regular participation from Harvard Medical School and the University of Zimbabwe. Participants report significant improvements in their physical exam skills and their appreciation of the needs of underserved populations, as well as confidence with global surgical concepts. Our Zimbabwean hosts thought the visitors integrated well into the clinical teams, added value to their own students' experience and believe that the exchange should continue despite the burden associated with hosting visiting students. CONCLUSIONS Here we detail the development of a course in global surgery for medical students that integrates didactic as well as clinical experiences in a low-resource setting. The course includes a true multilateral exchange with students from Sweden, the United States and Zimbabwe participating regularly. We hope that this course might serve as a model for other medical schools looking to establish courses in this burgeoning field.
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Access to Safe, Timely, and Affordable Surgical Care in Uganda: A Stratified Randomized Evaluation of Nationwide Public Sector Surgical Capacity and Core Surgical Indicators. World J Surg 2018; 42:2303-2313. [PMID: 29368021 DOI: 10.1007/s00268-018-4485-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Access to safe surgery is critical to health, welfare, and economic development. In 2015, the Lancet Commission on Global Surgery recommended that all countries collect surgical indicators to lend insight into improving surgical care. No nationwide high-quality data exist for these metrics in Uganda. METHODS A standardized quantitative hospital assessment and a semi-structured interview were administered to key stakeholders at 17 randomly selected public hospitals. Hospital walk-throughs and retrospective reviews of operative logbooks were completed. RESULTS This study captured information for public hospitals serving 64.0% of Uganda's population. On average, <25% of the population had 2 h access to a surgically capable facility. Hospitals averaged 257 beds/facilities and there were 0.2 operating rooms per 100,000 people. Annual surgical volume was 144.5 cases per 100,000 people per year. Surgical, anesthetic, and obstetrician physician workforce density was 0.3 per 100,000 people. Most hospitals reported having electricity, oxygen, and blood available more than half the time and running water available at least three quarters of the time. In total, 93.8% of facilities never had access to a CT scan. Sterile gloves, nasogastric tubes, and Foley catheters were frequently unavailable. Uniform outcome reporting does not exist, and the WHO safe surgery checklist is not utilized. CONCLUSION The Ugandan public hospital system does not meet LCoGS targets for surgical access, workforce, or surgical volume. Critical policy and programmatic developments are essential to build surgical capacity and facilitate provision of safe, timely, and affordable surgical care. Surgery must become a public health priority in Uganda and other low resource settings.
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Development of a Comprehensive Trauma Training Curriculum for the Resource-Limited Environment. JOURNAL OF SURGICAL EDUCATION 2018; 75:1317-1324. [PMID: 29555307 DOI: 10.1016/j.jsurg.2018.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/05/2018] [Accepted: 02/20/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The goal of this project was to create a multitiered trauma training curriculum that was designed specifically for the low-resource setting. DESIGN We developed 2 courses designed to teach principles and skills necessary for trauma care. The first course, "Emergency Ward Management of Trauma (EWMT)," is designed to teach interns the initial assessment and stabilization of trauma patients in the emergency ward. The second course for mid-level surgical residents, "Surgical Techniques and Repairs in Trauma for the Low-resource Environment" (STaRTLE), is a cadaver-based operative trauma course designed to teach surgical exposures and techniques. The courses were rolled out at Mbarara Regional Referral Hospital in the low-income country of Uganda. Precourse and postcourse tests and surveys were administered. SETTING This study took place at Mbarara Regional Referral Hospital (MRRH). This is a hospital in southwest Uganda with a subspecialty care, a medical school, nursing school, and multiple residency programs. PARTICIPANTS Students in the EWMT course were interns at MRRH. After 1 year of training, most of these interns will become medical officers as the only provider at a district hospital in Uganda. The students in the STARTLE course were second-year residents in the general surgery program at MRRH. RESULTS Scores on knowledge based tests improved significantly with both courses. Survey results from the EWMT course suggest that participants feel better prepared to care for the injured patient (median Likert [IQR]: 5.0 [5.0-5.0]) and that their practice improved (5.0 [5.0-5.0]). Similarly, following the STaRTLE course we found participants felt significantly more comfortable with performing 20 of the 22 operative procedures taught. CONCLUSIONS These courses represent a feasible, cost-effective, and resource appropriate trauma education curriculum that if standardized and implemented may improve trauma care and outcomes in the resource-limited setting.
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Derivation, Validation and Application of a Pragmatic Risk Prediction Index for Benchmarking of Surgical Outcomes. World J Surg 2018; 42:533-540. [PMID: 28795214 DOI: 10.1007/s00268-017-4177-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite the existence of multiple validated risk assessment and quality benchmarking tools in surgery, their utility outside of high-income countries is limited. We sought to derive, validate and apply a scoring system that is both (1) feasible, and (2) reliably predicts mortality in a middle-income country (MIC) context. METHODS A 5-step methodology was used: (1) development of a de novo surgical outcomes database modeled around the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) in South Africa (SA dataset), (2) use of the resultant data to identify all predictors of in-hospital death with more than 90% capture indicating feasibility of collection, (3) use these predictors to derive and validate an integer-based score that reliably predicts in-hospital death in the 2012 ACS-NSQIP, (4) apply the score in the original SA dataset and demonstrate its performance, (5) identify threshold cutoffs of the score to prompt action and drive quality improvement. RESULTS Following step one-three above, the 13 point Codman's score was derived and validated on 211,737 and 109,079 patients, respectively, and includes: age 65 (1), partially or completely dependent functional status (1), preoperative transfusions ≥4 units (1), emergency operation (2), sepsis or septic shock (2) American Society of Anesthesia score ≥3 (3) and operative procedure (1-3). Application of the score to 373 patients in the SA dataset showed good discrimination and calibration to predict an in-hospital death. A Codman Score of 8 is an optimal cutoff point for defining expected and unexpected deaths. CONCLUSION We have designed a novel risk prediction score specific for a MIC context. The Codman Score can prove useful for both (1) preoperative decision-making and (2) benchmarking the quality of surgical care in MIC's.
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You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PLoS One 2018; 13:e0195986. [PMID: 29664956 PMCID: PMC5903624 DOI: 10.1371/journal.pone.0195986] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/03/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. METHODS From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis. RESULTS The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need. CONCLUSION Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda's surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.
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Prevalence and risk factors for medical events following exercise at Australian Greyhound race meetings. Aust Vet J 2018; 96:120-126. [PMID: 29577254 DOI: 10.1111/avj.12678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 05/11/2017] [Accepted: 06/03/2017] [Indexed: 12/01/2022]
Abstract
AIM A prospective, observational study to determine the prevalence of post-exercise conditions at Australian Greyhound race meetings and to assess association with race performance and other environmental, race- and dog-related factors was undertaken. METHODS A total of 4020 starters were observed (2813 Greyhounds, 1009 trainers, 536 races, 52 race meets, 48 race dates and 11 race tracks) following a race. The presence of diaphragmatic flutter (DF), ataxia, seizure, collapse or sudden death was recorded. Risk factors were screened by univariable logistic regression prior to multivariable backward stepwise model building. RESULTS In this study, 962 starters (n = 768 dogs) had DF (23.9%), 16 starters were ataxic (0.4%) and there were no observed cases of collapse, seizure or sudden death. Race track location, increasing race distance, race grade based on increasing 1st place prize value, lower (earlier) race number at the meeting, age, a previous observation of DF at the last start, females, colour (white) and better finishing position were all associated with an increased risk of a Greyhound being observed with DF. However, when logistic regression assessing the random effect of dog was performed, the presence of previous DF was not significant. In this cohort, DF was common following strenuous exercise in Greyhounds and on its own does not appear to result in reduced performance or distress to the animal. CONCLUSION The incidence of ataxia was low and collapse, seizure and sudden death were not observed. However, even though uncommon, ataxia has welfare concerns for racing Greyhounds that warrants further investigation.
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Abstract
BACKGROUND The focus of many data collection efforts centers on creation of more granular data. The assumption is that more complex data are better able to predict outcomes. We hypothesized that data are often needlessly complex. We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) scoring system. METHODS First, we created every possible consecutive two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA. We compared the predictive ability of these simplified scores for postoperative outcomes for 2.3 million patients in the NSQIP database. Individual model performance was assessed by comparing receiver operator characteristic (ROC) curves for each model with the standard ASA. RESULTS Two of our 4-category models and one of our 3-category models had ability to predict all outcomes equivalent to standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the three best performing simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and when included in a multivariate model. CONCLUSIONS It is assumed that the most granular data and use of the largest number of variables for risk-adjusted predictions will increase accuracy. This complexity is often at the expense of utility. Using the single best predictor in surgical outcomes research, we have shown this is not the case. In this example, we demonstrate that one can simplify ASA into a 3-category variable without losing any ability to predict outcomes.
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Out-of-pocket payment for surgery in Uganda: The rate of impoverishing and catastrophic expenditure at a government hospital. PLoS One 2017; 12:e0187293. [PMID: 29088302 PMCID: PMC5663485 DOI: 10.1371/journal.pone.0187293] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 10/17/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is Ugandan governmental policy that all surgical care delivered at government hospitals in Uganda is to be provided to patients free of charge. In practice, however, frequent stock-outs and broken equipment require patients to pay for large portions of their care out of their own pocket. The purpose of this study was to determine the financial impact on patients who undergo surgery at a government hospital in Uganda. METHODS Every surgical patient discharged from a surgical ward at a large regional referral hospital in rural southwestern Uganda over a 3-week period in April 2016 was asked to participate. Patients who agreed were surveyed to determine their baseline level of poverty and to assess the financial impact of the hospitalization. Rates of impoverishment and catastrophic expenditure were then calculated. An "impoverishing expense" is defined as one that pushes a household below published poverty thresholds. A "catastrophic expense" was incurred if the patient spent more than 10% of their average annual expenditures. RESULTS We interviewed 295 out of a possible 320 patients during the study period. 46% (CI 40-52%) of our patients met the World Bank's definition of extreme poverty ($1.90/person/day). After receiving surgical care an additional 10 patients faced extreme poverty, and 5 patients were newly impoverished by the World Bank's definition ($3.10/person/day). 31% of patients faced a catastrophic expenditure of more than 10% of their estimated total yearly expenses. 53% of the households in our study had to borrow money to pay for care, 21% had to sell possessions, and 17% lost a job as a result of the patient's hospitalization. Only 5% of our patients received some form of charity. CONCLUSIONS AND RELEVANCE Despite the government's policy to provide "free care," undergoing an operation at a government hospital in Uganda can result in a severe economic burden to patients and their families. Alternative financing schemes to provide financial protection are critically needed.
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Augmented hamate replacement arthroplasty for fracture-dislocations of the proximal interphalangeal joints in 12 patients. J Hand Surg Eur Vol 2017; 42:799-802. [PMID: 28480780 DOI: 10.1177/1753193417707381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We report clinical outcomes in 12 patients with hemi-hamate replacement arthroplasty combined with volar plate arthroplasty. The volar plate was reattached using trans-osseous sutures to reconstruct the ligament-box complex after hamate grafting to augment the stability of the proximal interphalangeal joint. Ten patients had improved joint movement from a mean of 14° before surgery to a mean of 77° at a minimum follow-up of 2 years. Grip strength and pain of the affected hand and patient-rated hand and wrist scores were improved in these 10 patients. Two patients had poor results. One patient developed ankylosis, and one patient had resorption of the grafted bone. We conclude that the augmented hamate replacement arthroplasty is useful in treating chronic proximal interphalangeal joint fracture-dislocations. LEVEL OF EVIDENCE IV.
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Development of a Comprehensive Trauma Education Curriculum for the Resource-Limited Environment. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scintigraphic Assessment of Deposition of Radiolabeled Fluticasone Delivered from a Nebulizer and Metered Dose Inhaler in 10 Healthy Dogs. J Vet Intern Med 2017; 31:1849-1857. [PMID: 28961322 PMCID: PMC5697178 DOI: 10.1111/jvim.14832] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/17/2017] [Accepted: 08/21/2017] [Indexed: 11/30/2022] Open
Abstract
Background Aerosolized medications are increasingly being used to treat respiratory diseases in dogs. No previous studies assessing respiratory tract deposition of radiolabeled aerosols have been performed in conscious dogs. Hypothesis/Objectives Assess respiratory tract deposition of radiolabeled, inhalant corticosteroid (fluticasone propionate labeled with 99mTc) delivered from a nebulizer and metered dose inhaler (MDI) to healthy dogs. Animals Ten healthy Foxhounds. Methods Prospective, randomized, cross‐over pilot study. Initial inhalation method (nebulizer or MDI) was randomly assigned. Treatments were crossed over after a 7‐day washout period. Treatments initially were performed using sedation. Dogs were imaged using 2‐dimensional planar scintigraphy, with respiratory tract deposition quantified by manual region‐of‐interest analysis. Deposition calculated as percentage of delivered dose. Six of 10 dogs were randomly selected and reassessed without sedation. Results Inhalation method had significant effect on respiratory tract deposition (P = 0.027). Higher deposition was achieved by nebulization with mean deposition of 4.2% (standard deviation [SD], 1.4%; range, 1.9–6.1%); whereas MDI treatment achieved a mean of 2.3% (SD, 1.4%; range, 0.2–4.2%). Nebulization achieved higher respiratory tract deposition than MDI in 7 of 10 dogs. No statistical difference (P = 0.68) was found between mean respiratory tract deposition achieved in dogs when unsedated (3.8%; SD, 1.5%) or sedated (3.6%; SD, 1.7%). Conclusions and Clinical Importance Study confirms respiratory tract deposition of inhalant medications delivered from a nebulizer and MDI in healthy dogs, breathing tidally with and without sedation. Respiratory tract deposition in these dogs was low compared to reported deposition in adult humans, but similar to reported deposition in children.
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Validation of an Electronic Surgical Outcomes Database at Mbarara Regional Referral Hospital, Uganda. World J Surg 2017; 42:54-60. [DOI: 10.1007/s00268-017-4172-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Using global surgical indicators to improve trauma care in Latin America. BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2017; 102:11-16. [PMID: 28920641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings. Surgery 2017; 161:1710-1719. [PMID: 28259351 DOI: 10.1016/j.surg.2017.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data. METHODS For one month, every patient who underwent an operation at a referral hospital in western Uganda was observed. These patients and their outcomes were followed until discharge. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics. RESULTS Surgical volume at this regional hospital in Uganda is 8,515 operations/y, compared to 4,000 operations/y reported in the only other published data. The postoperative mortality rate at this hospital is 2.4%, similar to other hospitals in low-income countries. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts were significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths. CONCLUSION Our results describe a simple, reproducible, accurate, and inexpensive method for collection of the Lancet Commission on Global Surgery variables using logbooks that already exist in most hospitals in low-income countries. While some have suggested using risk-adjusted postoperative mortality rate as a more equitable variable, our data suggest that only a limited amount of risk adjustment is possible given the limited available data.
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High-quality care improves outcome in recumbent dairy cattle. Aust Vet J 2017; 94:173-80. [PMID: 27237117 DOI: 10.1111/avj.12445] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 06/14/2015] [Accepted: 07/14/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the influence of the quality of care on outcome and occurrence of secondary damage in recumbent dairy cows. METHODS Recumbent dairy cows were monitored during their recumbency under field conditions in South Gippsland, Victoria, Australia. The cause of the original recumbency of 218 downer cows was determined and any secondary damage, day 7 status, final outcome and the nursing conditions of the cows were recorded. A four-tiered grading system describing nursing quality was developed to allow analysis of its influence on outcome and on the occurrence of secondary damage. RESULTS Day 7 outcome, final outcome and occurrence of important secondary damage were very strongly associated with the level of overall care provided to the recumbent cows. There was a decrease in the percentage of cows recovering by day 7 from 33% to 0%, a decrease from 45% to 0% of cows eventually recovering and an increase from 68% to 100% of cows with clinically important secondary damage as overall care decreased. CONCLUSION Management of recumbent cattle is potentially a significant animal welfare issue for the dairy industry and their care is a very important but often under-appreciated aspect of their management. Recovery is positively influenced by high-quality care by improving the chances of recovery from the initial cause of recumbency and by reducing the occurrence of secondary damage. Recumbent cows must either be nursed at a high level of care or euthanased promptly.
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Mandatory Intensivist Management Decreases Length of Stay, Facilitates an Increase in Admissions and Minimizes Closure of a Neurocritical Care Unit. Neurocrit Care 2016. [PMID: 26209280 DOI: 10.1007/s12028-015-0148-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The primary objectives of this study were to identify patient and community benefits of mandatory intensivist management in a neurocritical care (NCC) unit. Our hospital recently mandated intensivist management for patients admitted to the NCC unit. As one of the only comprehensive stroke centers in Orlando, an unacceptably high number of patients were being denied admission because of overcapacity. We compared length of stay (LOS), complications, outcomes, total admissions, and emergency transfer center closure rates before and after implementation of mandatory intensivist management. METHODS A retrospective review comparing 1551 patients admitted to a 20 bed NCC unit from November 1, 2009 to October 31, 2010 (prior to mandatory intensivist management) with 1702 patients admitted from January 1, 2011 to December 31, 2011 (after the requirement) was performed. This included examining LOS, Acute Physiology and Chronic Health Evaluation III (APACHE) scores, service line closure rates, and mortality during both time periods. RESULTS Analysis revealed that despite comparable APACHE scores, implementation of mandatory intensivist management reduced overall NCC LOS, 4.6 versus 3.7 days, (p < 0.01) and increased the number of monthly admissions, 129 versus 142, (p = 0.02). The percentage of patients declined admission because of a closed service line was reduced from 12.36 to 5.66 %, (p = 0.02). Mortality and infection rates remained unchanged. CONCLUSIONS Implementation of mandatory intensivist management in the NCC unit decreased LOS, increased admissions, and decreased service line closure rates, while maintaining patient care.
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Importance of secondary damage in downer cows. Aust Vet J 2016; 94:138-44. [DOI: 10.1111/avj.12437] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 06/04/2015] [Accepted: 07/29/2015] [Indexed: 11/28/2022]
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Global Surgery 2030: a roadmap for high income country actors. BMJ Glob Health 2016; 1:e000011. [PMID: 28588908 PMCID: PMC5321301 DOI: 10.1136/bmjgh-2015-000011] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/06/2016] [Accepted: 01/19/2016] [Indexed: 12/16/2022] Open
Abstract
The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.
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An adaptable multiple power source for mass spectrometry and other scientific instruments. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2015; 86:094102. [PMID: 26429459 DOI: 10.1063/1.4930967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
An Adaptable Multiple Power Source (AMPS) system has been designed and constructed. The AMPS system can provide up to 16 direct current (DC) (±400 V; 5 mA), 4 radio frequency (RF) (two 500 VPP sinusoidal signals each, 0.5-5 MHz) channels, 2 high voltage sources (±6 kV), and one ∼40 W, 250 °C temperature-regulated heater. The system is controlled by a microcontroller, capable of communicating with its front panel or a computer. It can assign not only pre-saved fixed DC and RF signals but also profiled DC voltages. The AMPS system is capable of driving many mass spectrometry components and ancillary devices and can be adapted to other instrumentation/engineering projects.
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Building a global surgery initiative through evaluation, collaboration, and training: the Massachusetts General Hospital experience. JOURNAL OF SURGICAL EDUCATION 2015; 72:e21-e28. [PMID: 25697510 DOI: 10.1016/j.jsurg.2014.12.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/12/2014] [Accepted: 12/31/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE The Massachusetts General Hospital (MGH) Department of Surgery established the Global Surgery Initiative (GSI) in 2013 to transform volunteer and mission-based global surgery efforts into an educational experience in surgical systems strengthening. The objective of this newly conceived mission is not only to perform advanced surgery but also to train surgeons beyond MGH through international partnerships across disciplines. At its inception, a clear pathway to achieve this was not established, and we sought to identify steps that were critical to realizing our mission statement. SETTING Massachusetts General Hospital, Boston, MA, USA and Mbarara Regional Referral Hospital, Mbarara, Uganda PARTICIPANTS Members of the MGH and MRRH Departments of Surgery including faculty, fellows, and residents RESULTS The MGH GSI steering committee identified 4 steps for sustaining a robust global surgery program: (1) administer a survey to the MGH departmental faculty, fellows, and residents to gauge levels of experience and interest, (2) catalog all ongoing global surgical efforts and projects involving MGH surgical faculty, fellows, and residents to identify areas of overlap and opportunities for collaboration, (3) establish a longitudinal partnership with an academic surgical department in a limited-resource setting (Mbarara University of Science and Technology (MUST) at Mbarara Regional Referral Hospital (MRRH)), and (4) design a formal curriculum in global surgery to provide interested surgical residents with structured opportunities for research, education, and clinical work. CONCLUSIONS By organizing the collective experiences of colleagues, synchronizing efforts of new and former efforts, and leveraging the funding resources available at the local institution, the MGH GSI hopes to provide academic benefit to our foreign partners as well as our trainees through longitudinal collaboration. Providing additional financial and organizational support might encourage more surgeons to become involved in global surgery efforts. Creating a partnership with a hospital in a limited-resource setting and establishing a formal global surgery curriculum for our residents allows for education and longitudinal collaboration. We believe this is a replicable model for building other academic global surgery endeavors that aim to strengthen health and surgical systems beyond their own institutions.
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Evaluation of prognostic indicators for canine primary immune-mediated haemolytic anaemia and application of a scoring system for the determination of prognosis. Aust Vet J 2015; 93:93-8. [PMID: 25817973 DOI: 10.1111/avj.12302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Apply a previously described scoring system retrospectively to cases of canine primary immune-mediated haemolytic anaemia (pIMHA) to determine its accuracy and reliability for the determination of prognosis in Victoria, Australia. METHODS Retrospective cohort study of 41 dogs diagnosed with pIMHA at the University of Melbourne Veterinary Hospital (UMVH) between August 2006 to December 2012. RESULTS Of the 41 dogs included, 70.7% were female while 29.3% were male. The overall mortality in this study was 43.9%. The previously described prognostic scoring system when applied to cases of pIMHA in Victoria, Australia, was not found to show statistical significance for prognostification. None of the five prognostic factors were found to be independently significant for prognostification. CONCLUSION Application of the previously described prognostic scoring system indicated that it may not be reliable for predicting prognoses of dogs with pIMHA in Victoria, Australia.
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The effects on ruminal pH and serum haptoglobin after feeding a grain-based supplement to grazing dairy cows as a partial mixed ration or during milking. Vet J 2015; 204:105-9. [PMID: 25744799 DOI: 10.1016/j.tvjl.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 02/03/2015] [Accepted: 02/04/2015] [Indexed: 11/15/2022]
Abstract
Ruminal pH and serum concentrations of haptoglobin (Hp) were measured in order to assess the risk of subacute ruminal acidosis (SARA) in grazing cows offered rolled wheat grain twice daily in the dairy at milking (Control group; n= 64), or as a partial mixed ration (PMR group; n= 64) on a feedpad. Cows were allocated various levels of the supplement (8, 10, 12 or 14 kg dry matter/day). Ruminal pH was measured in 16 rumen-fistulated cows (eight PMR and eight Control group cows), using indwelling pH meters, recording every 10 min for 14 days. Serum Hp was analysed in samples collected from 125 cows. No differences in ruminal pH or serum Hp concentration were found between treatment groups, or levels of feeding. It was concluded that, using ruminal pH patterns and Hp as markers of SARA at the feeding levels used in this study, there were no differences between grazing cows fed the supplement either as grain in the dairy or as a PMR fed on a feedpad.
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Prospective study of the association between exercise-induced pulmonary haemorrhage and long-term performance in Thoroughbred racehorses. Equine Vet J 2014; 47:350-7. [PMID: 24617564 DOI: 10.1111/evj.12263] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 02/26/2014] [Indexed: 11/28/2022]
Abstract
REASONS FOR PERFORMING STUDY Exercise-induced pulmonary haemorrhage (EIPH) is associated with impaired short-term race performance but consequences to long-term race performance of Thoroughbred racehorses are unknown. Knowledge of effects of EIPH on performance over a prolonged time would inform the need for management and treatment of this disorder. OBJECTIVES To determine the relationship between EIPH detected on a single occasion and long-term athletic performance in Thoroughbred racehorses. STUDY DESIGN Prospective, longitudinal, observational epidemiological study conducted from 2003 to 2012. METHODS Seven hundred and forty-four Thoroughbred racehorses underwent a single tracheobronchoscopic examination to determine presence and severity of EIPH in 2003. Following retirement of all the horses from racing, career after examination and lifetime performance data (including career duration, earnings, starts, wins and placings) were abstracted from a commercial database. The association between presence and severity of EIPH and individual performance variables were analysed using survival analysis, linear regression and negative binomial regression. RESULTS No association was detected between the presence of any EIPH (grade ≥1) and all measures of long-term performance examined except that horses with EIPH (grade ≥2) had fewer earnings after endoscopic examination than did horses with mild EIPH or no EIPH (grades ≤1). Multiple associations were detected between the most severe form of EIPH (grade 4) and measures of long-term performance suggesting that the severity of EIPH commonly associated with epistaxis adversely affects either the horse's opportunity to race or physiologic capacity to race. CONCLUSIONS We conclude that there is no association between EIPH grades 0, 1, 2 and 3 and long-term racing performance of Thoroughbred racehorses. These results are based on a single endoscopic evaluation of EIPH grade made during a horse's career. Further studies are required to determine the reasons for an association of severe (grade 4) EIPH with impaired long-term race performance.
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Risk of septic arthritis after intra-articular medication: a study of 16,624 injections in Thoroughbred racehorses. Aust Vet J 2014; 91:268-73. [PMID: 23782019 DOI: 10.1111/avj.12073] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The aims of this study were to determine the risk of septic arthritis after intra-articular medication (IAM) and to identify potential risk factors for this complication. DESIGN A retrospective and prospective descriptive study of prevalence, and matched case-control study for risk factors. RESULTS Of 16,624 joints injected in 1103 horses at 6695 horse-visits, septic arthritis occurred as a complication in 13 joints (13 horses). The risk of septic arthritis following IAM was 7.8 cases per 10,000 injections or 1 case per 1279 injections. Veterinarian and type of corticosteroid were identified as risk factors. CONCLUSIONS Septic arthritis is an uncommon complication of IAM in horses, yet the risk is substantially higher than that reported in humans. The risk was higher for some veterinarians; identifying the reason for this was beyond the scope of this study, yet we presume they may have paid less attention to strict aseptic technique. A larger study may be needed to clarify whether the risk is greater with certain types of corticosteroids and to identify additional risk factors.
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An assessment of intra- and interobserver agreement of reporting orthopaedic findings on presale radiographs of Thoroughbred yearlings. Equine Vet J 2013; 46:567-74. [PMID: 23889034 DOI: 10.1111/evj.12150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 07/16/2013] [Indexed: 11/26/2022]
Abstract
REASONS FOR PERFORMING STUDY Radiography is commonly used in clinical practice but agreement of reporting of radiographically detected orthopaedic findings in horses has rarely been studied. OBJECTIVES To assess agreement within and between observers for reporting of orthopaedic findings on presale radiographs of Thoroughbred yearlings. STUDY DESIGN Retrospective analysis of archived radiographs. METHODS Four veterinary radiology specialists each twice examined 167 sets of radiographs for orthopaedic findings in the fore feet, fore and hind fetlocks, carpi, tarsi and stifles. There were 27 findings analysed for agreement. Kappa statistic (κ), percentage of positive agreement (Ppos) and percentage of negative agreement are reported. RESULTS An excellent percentage of negative agreement was observed for all findings, with the exception of regular vascular channels of the proximal sesamoid bones. Ppos and κ results were variable. The presence of extra carpal bones, osseous cyst-like lesions of the ulnar carpal bone, sagittal ridge defects of the third metacarpus, fracture of the fore and hind proximal sesamoid bones, regular vascular channels in the hind proximal sesamoids, osteochondrosis lesions of the distal intermediate ridge and/or medial malleoli of the tibia, and osseous cyst-like lesions in the medial femoral condyle was consistently observed with an intra- and interagreement κ≥0.5 and Ppos≥50%. Lucency within the proximal sesamoids consistently had an observed intra- and interagreement κ<0.4 and Ppos<40%. CONCLUSIONS Observation of orthopaedic findings on yearling repository radiographs showed generally excellent agreement on the absence of findings, but variable agreement on the presence of findings. Agreement was good for larger and easy to categorise radiographic findings. More accurate definitions and training need to be developed to improve agreement within and between observers for orthopaedic findings with poor or fair to good agreement.
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Bioequivalence of a new liquid formulation of benazepril compared with the reference tablet product. Aust Vet J 2013; 91:312-9. [PMID: 23889096 DOI: 10.1111/avj.12080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare the bioequivalence and 'switchability' of two formulations of benazepril (tablet and liquid) after oral administration. DESIGN Randomised cross-over design, followed by parallel comparison. METHODS Twelve mixed-breed dogs were administered either a tablet (Group A) or liquid formulation (Group B) of benazepril orally at 0.45 mg/kg daily for 4 days. With no washout period, the dogs then received the alternative treatment at the same dose for a further 4 days. Blood samples taken prior to treatment and serially after treatment were analysed for plasma concentrations of benazepril and benazeprilat and the activity and concentration of angiotensin-converting enzyme (ACE). The calculated percentage inhibition of ACE was defined as the primary outcome variable. RESULTS No statistically significant differences were found between groups A and B for any variable evaluated. The mean (± SD) percentage of ACE inhibition was 85.5 ± 7.04% for the liquid formulation and 85.9 ± 6.66% for the tablet formulation. The mean of the ratios was 1.00 (80% confidence interval 0.96-1.04). No evaluated effect term (sequence, formulation or period) had any statistical effect on any outcome variable. CONCLUSION This study supports a conclusion that, based on pharmacodynamic response, the liquid formulation of benazepril is bioequivalent to the reference tablet formulation. Further, the lack of a sequence effect supports the switchability of these two formulations.
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Exercise-induced inhibition of remodelling is focally offset with fatigue fracture in racehorses. Osteoporos Int 2013; 24:2043-8. [PMID: 23371360 DOI: 10.1007/s00198-013-2291-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/14/2012] [Indexed: 11/26/2022]
Abstract
UNLABELLED Bone remodelling is inhibited by high repetitive loading. However, in subchondral bone of racehorses in training, eroded surface doubled in association with fatigue fracture and there was greater surrounding trabecular bone volume suggesting trabecular modelling unloads the bone focally, allowing damage repair by remodelling. INTRODUCTION Remodelling replaces damaged bone with new bone but is suppressed during high magnitude repetitive loading when damage is most likely. However, in cortical bone of racehorses, at sites of fatigue fracture, focal porosity, consistent with remodelling, is observed in proportion to the extent of surrounding callus. Focal areas of porosity are also observed at sites of fatigue damage in subchondral bone. We hypothesised that fatigued subchondral bone, like damaged cortical bone, is remodelled focally in proportion to the modelling of surrounding trabecular bone. METHODS Eroded and mineralizing surfaces and bone area were measured using backscattered scanning electron microscopy of post-mortem specimens of the distal third metacarpal bone in 11 racehorses with condylar fractures (cases) and eight racehorses in training without fractures (controls). RESULTS Cases had a two-fold greater eroded surface per unit area at the fracture site than controls (0.81 ± 0.10 vs. 0.40 ± 0.12 mm(-1), P = 0.021) but not at an adjacent site (0.22 ± 0.09 vs. 0.30 ± 0.11 mm(-1), P = 0.59). Area fraction of surrounding trabecular bone was higher in cases than controls (81 ± 2 vs. 72 ± 2 %, P = 0.0020) and the eroded surface at the fracture site correlated with the surrounding trabecular area (adjusted R (2) = 0.63, P = 0.0010). CONCLUSION In conclusion, exercise-induced inhibition of remodelling is offset at sites of fatigue fracture. Modelling of trabecular bone may contribute to unloading these regions, allowing repair by remodelling.
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Effect of displaced versus non-displaced pelvic fractures on long-term racing performance in 31 Thoroughbred racehorses. Aust Vet J 2013; 91:246-50. [DOI: 10.1111/avj.12053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2012] [Indexed: 11/28/2022]
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Sedation of hyperthyroid cats with subcutaneous administration of a combination of alfaxalone and butorphanol. Aust Vet J 2013; 91:131-6. [DOI: 10.1111/avj.12034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2012] [Indexed: 11/27/2022]
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Effect of simulated stages of the canine oestrous cycle on Escherichia coli binding to canine endometrium. Reprod Domest Anim 2013; 47 Suppl 6:331-4. [PMID: 23279531 DOI: 10.1111/rda.12101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pyometra, a prevalent infectious uterine disease that affects intact middle-aged bitches, is typically associated with Escherichia coli. Our hypotheses were (i) that bacterial adhesion to canine endometrium differs between different stages of the oestrous cycle and (ii) that the adhesin FimH facilitates this adhesion. Twelve post-pubertal, ovariectomized greyhound bitches were treated with exogenous hormones to simulate different stages of the oestrous cycle. Tissue samples from each uterus were incubated with a pathogenic E. coli strain carrying the fimH gene, but no other adhesin genes (P4-wt)--or an E. coli strain in which fimH was insertionally inactivated (P4-∆fimH::kan)--or with phosphate-buffered saline as a negative control. After washing, tissue samples were homogenized for quantification of adherent bacteria. The differences in binding to canine endometrium at different stages of the oestrous cycle were not significant. However, the mean difference in binding of the P4-wt and the P4-∆fimH::kan across all stages of the simulated oestrous cycle was significant (p < 0.001 by paired t-test on geometric means). Individual differences in numbers of P4-wt bacteria bound between dogs might suggest genetic variations or epigenetic differences in FimH receptor expression by the endometrium, unrelated to the stage of the oestrous cycle.
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Hoof conformation and performance in the racing Thoroughbred in Macau. Aust Vet J 2012; 91:108-12. [DOI: 10.1111/avj.12012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2012] [Indexed: 11/30/2022]
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Large Molecule Characterization Based upon Individual Ion Detection with Electrospray Ionization-FTICR Mass Spectrometry. Anal Chem 2012; 70:519-25. [PMID: 21644751 DOI: 10.1021/ac9711706] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a new method for mass spectrometric measurements of high-molecular-weight species based on the summation of sequential Fourier transform ion cyclotron resonance (FTICR) spectra of individual multiply charged ions. This approach produces statistically useful mass spectra for large multiply charged molecular species formed by electrospray ionization and circumvents conventional limitations upon achievable resolving power and precision for high-molecular-weight species which arise due to Coulombic constraints. For very large molecules with tens to thousands of charges each, the total number of charges required to define the charge-state distribution, and thus provide accurate mass information, greatly exceeds the useful charge capacity of the FTICR cell. As trapped ion populations approach or exceed this capacity, FTICR performance degrades due to large frequency shifts, peak coalescence phenomena, and rapid loss of ion packet coherence, which effectively precludes high-resolution and precision measurements for molecules above ∼80-kDa size for a 7-T magnetic field strength. The present approach is based on the summation of many spectra having moderate populations of individual ions and relies on sensitivity sufficient for individual ion detection. While the number of trapped ions contributing to each mass spectrum may generally be insufficient to define the isotopic or charge-state distributions (and thus produce accurate information on the molecular weight distribution in a conventional fashion), the present data processing and summation approach suppresses the noise component (as well as smaller signals) that would otherwise be problematic. Importantly, this approach circumvents natural limitations for very high molecular weight species due to Coulombic interactions and thus provides a basis for much greater resolution and mass measurement accuracy than otherwise possible. This paper presents the details of this approach and its demonstration for the 66-kDa protein bovine serum albumin (where the conventional approach is also feasible) and discusses important aspects of the data manipulation.
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