Andreas Wladis

Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial.

Objective:To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications. Summary Background Data:Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications. Methods:A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled. Intervention:Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication. Results:An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3–40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant. Conclusion:Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey.

In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

High body mass index is associated with increased risk of implant dislocation following primary total hip replacement: 2,106 patients followed for up to 8 years

Background and purpose Implant dislocation is one of the commonest complications following primary total hip replacement (THR). We investigated the effect of body mass index (BMI) and tobacco use on the risk of this complication. Subjects and methods Through linkage between the Swedish Construction Workers’ cohort and the Swedish Inpatient Register, 2,106 male patients who had undergone primary THR between 1997 and 2004 were identified. We used Cox multivariable regression analysis to study the association between BMI and tobacco use and the risk of implant dislocation. Results 53 patients (2.5%) developed implant dislocation during a mean of 2 (0–3) years of follow-up. We found overweight and obesity to be associated with increased risk of implant dislocation (HR = 2.5,95% CI: 1.1–5.5 and HR = 3.7, 95% CI: 1.5–9.3, respectively as compared to those of normal weight). There was no statistically significant association between tobacco use and the risk of dislocation. Interpretation Greater attention should be given to high BMI as a risk factor for implant dislocation following THR.

Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries

In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.

The efficacy of a smoking cessation programme in patients undergoing elective surgery – a randomised clinical trial

It is known that smokers constitute an important risk group of patients undergoing surgery. It is unknown how smoking cessation intervention initiated 4 weeks prior to elective surgery affects the probability of permanent cessation. We randomly assigned 117 patients, scheduled to undergo elective orthopaedic and general surgery, to smoking cessation intervention and control group. The intervention group underwent a programme initiated, on average, 4 weeks prior to surgery with weekly meetings or telephone counselling and were provided with free nicotine replacement therapy (NRT). The control group received standard care. As a result, 20/55 (36%) patients the intervention group vs 1/62 (2%) in the control group became completely abstinent throughout the peri‐operative period (p < 0.001). After 1 year, those in the intervention group was most likely to be abstinent (18/55 (33%) vs 9/62 (15%) of the controls (p = 0.03). Level of nicotine dependence and obesity seemed to be a predictor of long‐term abstinence (p = 0.02).

A Randomized Trial of Low-Cost Mesh in Groin Hernia Repair

BACKGROUND The most effective method for repair of a groin hernia involves the use of a synthetic mesh, but this type of mesh is unaffordable for many patients in low- and middle-income countries. Sterilized mosquito meshes have been used as a lower-cost alternative but have not been rigorously studied. METHODS We performed a double-blind, randomized, controlled trial comparing low-cost mesh with commercial mesh (both lightweight) for the repair of a groin hernia in adult men in eastern Uganda who had primary, unilateral, reducible groin hernias. Surgery was performed by four qualified surgeons. The primary outcomes were hernia recurrence at 1 year and postoperative complications. RESULTS A total of 302 patients were included in the study. The follow-up rate was 97.3% after 2 weeks and 95.6% after 1 year. Hernia recurred in 1 patient (0.7%) assigned to the low-cost mesh and in no patients assigned to the commercial mesh (absolute risk difference, 0.7 percentage points; 95% confidence interval [CI], -1.2 to 2.6; P=1.0). Postoperative complications occurred in 44 patients (30.8%) assigned to the low-cost mesh and in 44 patients (29.7%) assigned to the commercial mesh (absolute risk difference, 1.0 percentage point; 95% CI, -9.5 to 11.6; P=1.0). CONCLUSIONS Rates of hernia recurrence and postoperative complications did not differ significantly between men undergoing hernia repair with low-cost mesh and those undergoing hernia repair with commercial mesh. (Funded by the Swedish Research Council and others; Current Controlled Trials number, ISRCTN20596933.).

Impact of body mass index and tobacco smoking on outcome after open appendicectomy

The effect of body mass index (BMI) and smoking on the risk of perforated appendix and postoperative complications in patients undergoing open appendicectomy for acute appendicitis was studied.

Acute hemodynamic effects of induced hypothermia in hemorrhagic shock: an experimental study in the pig.

Hypothermia (HT) is used in certain surgical procedures to reduce metabolism and protect the brain, but in trauma victims accidental HT is considered harmful. Recent animal studies indicate that HT has protective effects in hemorrhagic shock. The aim of the present study was to examine how induced HT modifies the hemodynamic pattern in hemorrhagic shock. Twenty pigs with a body weight of between 17 and 24 kg (mean 20.8) were anesthetized, 50% of their blood volume was withdrawn, and hypothermia (30 degrees C) was induced in half of them (HT group) while the others served as controls. Central hemodynamics was monitored during 4 h via an arterial line and a pulmonary artery catheter. Blood samples were obtained for measurement of leukocyte and platelet counts. Three of the control pigs died while all the animals in the HT group survived the experiment. The hemorrhage resulted in a marked increase in heart rate and a drop in cardiac output and mean arterial pressure. HT slowed the heart rate and induced a further reduction of cardiac output, which parallelled the depression of the core temperature, while the stroke volume did not change in any of the groups. A significant decrease in mean arterial pressure and the leukocyte count became apparent 2 h after the induction of HT. HT aggravated the hypokinetic situation resulting from hemorrhagic shock but without increasing the mortality.

Foreign field hospitals after the 2010 Haiti earthquake: how good were we?

Objective To assess the timing and activities of foreign field hospitals (FFH) deployed during the first month after the Haiti earthquake and to evaluate adherence to WHO/Pan American Health Organization (PAHO) guidelines. Results were compared with data from past sudden-onset disasters. Methods A systematic attempt was made to contact all relief actors within the health care sector involved in the 12 January through 12 February 2010 FFH deployment. This was done using an email-based questionnaire and a web survey. In addition, the authors undertook a literature review using PubMed and the Google search engine between March 2010 and May 2011. The authors contacted key informants and agencies identified by direct observations in the field by email or phone. Results A total of 44 FFH were identified. The first FFH was operational on day two post-earthquake. The number of FFH beds peaked at about 3300 on day 17 post-earthquake. During the first month, the authors estimate that FFH conducted no more than 12 000 major surgical operations. While 25% of the FFH adhered to either WHO/PAHO first essential deployment requirements, none followed both requirements of WHO/PAHO. Compared with the 2005 earthquake in Pakistan, twice as many FFH provided medical care, resulting in three times more FFH beds. Conclusions The present study suggests that more FFH were sent to Haiti than to any previous sudden-onset disasters, but due to lack of data and transparency it remains impossible to determine to what extent did the first wave of FFH do any good in Haiti.