Catherine Juillard

Developing Priorities for Addressing Surgical Conditions Globally: Furthering the Link Between Surgery and Public Health Policy

BackgroundEfforts to promote wider access to surgical services globally would be aided by developing consensus among clinicians, the public health policy community, and other stakeholders as to which surgical conditions warrant the most focused attention and investment. This would add value to other, ongoing efforts, especially in helping to define unmet need and effective coverage.MethodsIn this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Factors that would come into play in this process include the public health burden of the condition and the successfulness and feasibility of the procedures to treat those conditions.Results and conclusionsThe implications of the prioritization process are that those conditions with the highest public health burden and that have procedures that are highly successful and feasible to promote globally, including in the most resource-constrained environments, should be the main focus of national and international efforts.

The Burden of Road Traffic Injuries in Nigeria: Results of a Population-Based Survey

Background: Mortality from road traffic injuries in sub-Saharan Africa is among the highest in the world, yet data from the region are sparse. To date, no multi-site population-based survey on road traffic injuries has been reported from Nigeria, the most populated country in Africa. Objective: To explore the epidemiology of road traffic injury in Nigeria and provide data on the populations affected and risk factors for road traffic injury. Design: Data from a population-based survey using two-stage stratified cluster sampling. Subjects/setting: Road traffic injury status and demographic information were collected on 3082 respondents living in 553 households in seven of Nigeria’s 37 states. Main outcome measures: Incidence rates were estimated with confidence intervals based on a Poisson distribution; Poisson regression analysis was used to calculate relative risks for associated factors. Results: The overall road traffic injury rate was 41 per 1000 population (95% CI 34 to 49), and mortality from road traffic injuries was 1.6 per 1000 population (95% CI 0.5 to 3.8). Motorcycle crashes accounted for 54% of all road traffic injuries. The road traffic injury rates found for rural and urban respondents were not significantly different. Increased risk of injury was associated with male gender among those aged 18–44 years, with a relative risk of 2.96 when compared with women in the same age range (95% CI 1.72 to 5.09, p<0.001). Conclusions: The road traffic injury rates found in this survey highlight a neglected public health problem in Nigeria. Simple extrapolations from this survey suggest that over 4 million people may be injured and as many as 200 000 potentially killed as the result of road traffic crashes annually in Nigeria. Appropriate interventions in both the health and transport sectors are needed to address this significant cause of morbidity and mortality in Nigeria.

Establishing the Evidence Base for Trauma Quality Improvement: A Collaborative WHO-IATSIC Review

BackgroundQuality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.MethodsThe review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.ResultsThirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.ConclusionsTrauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

A National Analysis of the Relationship Between Hospital Volume, Academic Center Status, and Surgical Outcomes for Abdominal Hysterectomy Done for Leiomyoma

BACKGROUND Volume-to-outcomes relationships have been established for high-risk surgical procedures. To determine whether hospital volume and academic center status affect surgical outcomes in a lower-risk procedure, morbidity and mortality in patients undergoing abdominal hysterectomy for leiomyoma were evaluated. STUDY DESIGN Administrative data from the National Inpatient Sample were used to conduct a retrospective analysis of 172,344 individuals who had primary diagnoses of leiomyomata (ICD-9 diagnosis codes of 218.x in the first 2 positions) and who underwent abdominal hysterectomy (ICD-9 procedure codes 68.4 in the first 2 positions) from 1999 to 2003. Comparison was made between teaching hospitals versus nonteaching hospitals and annual case volume in quintiles. Morbidity was considered to be any postoperative condition that is not an expected outcome of hysterectomy and defined as instances in which a patient suffered hemorrhage, ureteral injury, bladder injury, intestinal injury, wound dehiscence, wound infection, deep vein thrombosis, pulmonary embolism, or required blood transfusion. RESULTS A total of 37 deaths were observed. Mortality was not significantly related to hospital volume or academic medical center status. In contrast, morbidity was found to have a positive association with academic medical center status (odds ratio = 1.34; 95% CI, 1.23 to 1.45), although an inverse relationship between volume and morbidity was observed for extended length of stay (> 3 days) and blood transfusion outcomes in the first 3 (lowest) volume quintiles and for pulmonary embolism in the highest-volume quintile. No important association with volume was found for hemorrhage, ureteral injury, bladder injury, or intestinal injury. CONCLUSIONS Unlike high-risk procedures, such as esophagectomy, pediatric cardiac surgery, and pancreaticoduodenectomy, mortality for abdominal hysterectomy done for benign indication does not improve with hospital volume or academic center status. The statistically significant positive association between academic medical center status and morbidity merits additional characterization to target areas for improvement.

Hospital-based injury data from level III institution in Cameroon: retrospective analysis of the present registration system.

BACKGROUND Data on the epidemiology of trauma in Cameroon are scarce. Presently, hospital records are still used as a primary source of injury data. It has been shown that trauma registries could play a key role in providing basic data on trauma. Our goal is to review the present emergency ward records for completeness of data and provide an overview of injuries in the city of Limbe and the surrounding area in the Southwest Region of Cameroon prior to the institution of a formal registration system. METHODS A retrospective review of Emergency Ward logs in Limbe Hospital was conducted over one year. Records for all patients over 15 years of age were reviewed for 14 data points considered to be essential to a basic trauma registry. Completeness of records was assessed and a descriptive analysis of patterns and trends of trauma was performed. RESULTS Injury-related conditions represent 27% of all registered admissions in the casualty department. Information on age, sex and mechanism of injury was lacking in 22% of cases. Information on vital signs was present in 2% (respiratory rate) to 12% (blood pressure on admission) of records. Patient disposition (admission, transfer, discharge, or death) was available 42% of the time, whilst location of injury was found in 84% of records. Road traffic injury was the most frequently recorded mechanism (36%), with the type of vehicle specified in 54% and the type of collision in only 22% of cases. Intentional injuries were the second most frequent mechanism at 23%. CONCLUSION The frequency of trauma found in this context argues for further prevention and treatment efforts. The institution of a formal registration system will improve the completeness of data and lead to increased ability to evaluate the severity and subsequent public health implications of injury in this region.

Interferon-β induces brain-derived neurotrophic factor in peripheral blood mononuclear cells of multiple sclerosis patients

Interferon-beta (IFN-beta) achieves its beneficial effect on multiple sclerosis (MS) via anti-inflammatory properties. In this study, we assessed the expression of the brain-derived neurotrophic factor (BDNF) in peripheral blood mononuclear cells (PBMC) from relapsing-remitting multiple sclerosis (RRMS) patients treated or not with IFN-beta. Intracellular BDNF was measured by Western blot and ELISA and compared with serum BDNF. We found higher levels of BDNF in PBMC of IFN-beta-treated versus non-treated patients, whereas serum levels of BDNF were similar. We hypothesize that the increased intracellular BDNF secondary to IFN-beta is not released in the periphery. This release is probably not tissue specific but in MS patients, BDNF could be specifically delivered by PBMC at the site of re-activation, i.e. within the central nervous system.

Socioeconomic impact of road traffic injuries in West Africa: exploratory data from Nigeria

Background Road traffic injuries (RTIs) are increasingly contributing to the burden of disease in sub-Saharan Africa, yet little is known about the economic consequences and disability associated with them. Objective To explore cost and disability consequences of RTIs in Nigeria. Design A population-based survey using two-stage stratified cluster sampling. Subject/setting Information on care-seeking choice, cost of treatment, ability to work, reduction in earnings, and disability were collected on 127 subjects who had suffered an RTI, of 3082 study subjects in seven Nigerian states. Outcome measures Univariate analysis was used to estimate frequency of disability, types of care sought, and trends for work lost, functional ability and cost of treatment. Unadjusted bivariate analysis was performed to explore care-seeking, cost of care, and work lost among disabled and non-disabled people. Results RTIs resulted in disability for 29.1% of subjects, while 13.5% were unable to return to work. Of the disabled people, 67.6% were unable to perform activities of daily living, 16.7% consequently lost their jobs, and 88.6% had a reduction in earnings. Private physician and hospital treatment were the most common forms of initial treatment sought, but traditional treatment was the most common second form of care sought. Average direct costs of informal and formal treatment were US

Infection following deep brain stimulator implantation performed in the conventional versus magnetic resonance imaging-equipped operating room.

6.65 and US

Saving lives and saving money: hospital-based violence intervention is cost-effective

35.64, respectively. Disabled people were more likely to seek formal care (p=0.003) and be unable to work (p=0.002). Conclusions Economic and functional ramifications must be included in the spectrum of consequences of RTIs to fully appreciate the extent of the burden of disease, implying that health systems should not only address the clinical consequences of RTIs, but the financial ones as well.

Strengthening care of injured children globally

OBJECT Risk factors for deep brain stimulator (DBS) infection are poorly defined. Because DBS implants are not frequently performed in the MR imaging-equipped operating room (OR), no specific data about infection of DBS implants performed in the MR imaging environment are available in the literature. In this study the authors focus on the incidence of infection in patients undergoing surgery in the conventional versus MR imaging-equipped OR. METHODS To identify cases of DBS-associated infection, the authors performed a retrospective cohort study with nested case-control analysis of all patients undergoing DBS implantation at the University of California Los Angeles Medical Center. Cases of DBS infection were identified using standardized clinical and microbiological criteria. RESULTS Between January 1998 and September 2003, 228 DBSs were implanted. Forty-seven operations (20.6%) were performed in the conventional OR and 181 (79.4%) in the MR imaging-equipped OR. There was definite infection in 13 cases (5.7%) and possible infection in 7 cases (3%), for an overall infection rate of 8.7% (20 of 228 cases). There was no significant difference in infection rates in the conventional (7 [14.89%] of 47) versus MR imaging-equipped OR (13 [7.18%] of 181) (p = 0.7). Staphylococcus aureus was isolated in 62% of cases. Twelve of 13 confirmed cases underwent complete hardware removal. On case-control analysis, younger age (< or = 58.5 years) was a significant predictor of DBS infection (odds ratio 3.4, p = 0.027) CONCLUSIONS Infection is a serious complication of DBS implantation and commonly requires device removal for cure. The authors found that DBS implantation can be safely performed in MR imaging-equipped suites, possibly allowing improved lead placement. Young age was associated with an increased risk of DBS infection.