Chris Lavy

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anesthesia care in low- and middleincome countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer. Although the term, low- and middleincome countries (LMICs), has been used throughout the report for brevity, the Commission realizes that tremendous income diversity exists between and within this group of countries. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, noncommunicable diseases, and injuries. Surgical and anesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anesthesiacare,whichshouldbeavailable, affordable,timely,andsafetoensuregood coverage, uptake, and outcomes. Despite a growing need, the develop

Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world?

This study looks at whether orthopaedic clinical officers, a cadre of clinicians who are not doctors, can effectively manipulate idiopathic clubfeet using the Ponseti technique. One hundred consecutive cases of uncomplicated idiopathic clubfeet in newborn babies were manipulated by orthopaedic clinical officers. Fifty-seven of these were fully corrected to a plantigrade position by Ponseti manipulation alone, and a further 41 were corrected by manipulation followed by a simple percutaneous tenotomy. Orthopaedic clinical officers therefore corrected 98 out of 100 feet; the remaining 2 feet were referred for surgical correction. This shows that the Ponseti method is suitable for use by nonmedical personnel in the developing world to achieve a plantigrade foot.

Systematic Review of Met and Unmet Need of Surgical Disease in Rural Sub-Saharan Africa

BackgroundLittle is known about the burden of surgical disease in rural sub-Saharan Africa, where district and rural hospitals are the main providers of care. The present study sought to analyze what is known about the met and unmet need of surgical disease.MethodsThe PubMed and EMBASE databases were searched for studies of surveys in rural areas, information on surgical admissions, and operations performed within rural and district hospitals. Data were extrapolated to calculate the amount of surgical disease per 100,000 population and the number of operations performed per 100,000 population. These extrapolations were used to estimate the total, the met, and the unmet need of surgical disease.ResultsThe estimated overall incidence of nonfatal injury is at least 1,690/100,000 population per year. Morbidity as a result of injury is up to 190/100,000 population per year, and the annual mortality from injury is 53–92/100,000. District hospitals perform 6 fracture reductions (95% CI: 0.1–12)/100,000 population per year and 14 laparotomies (95% CI: 7–21)/100,000 per year. The incidence of peritonitis and bowel obstruction is unknown, although it may be as high as 1,364/100,000 population for the acute abdomen. The annual total need for inguinal hernia repair is estimated to be a minimum of 205/100,000 population. The average district hospital performs 30 hernia repairs (95% CI: 18–41)/100,000 population per year, leaving an unmet need of 175/100,000 population annually.ConclusionsDistrict hospitals are not meeting the surgical needs of the populations they serve. Urgent intervention is required to build up their capacity, to train healthcare personnel in safe surgery and anesthesia, and to overcome obstacles to timely emergency care.

Wound healing after implant surgery in HIV-positive patients

We performed a prospective, blind, controlled study on wound infection after implant surgery involving 41 procedures in patients infected with the human immunodeficiency virus (HIV) and 141 in HIV-negative patients. The patients were staged clinically and the CD4 cell count determined. Wound infection was assessed using the asepsis wound score. A risk category was allocated to account for presurgical contamination. In HIV-positive patients, with no preoperative contamination, the incidence of wound infection (3.5%) was comparable with that of the HIV-negative group (5%; p = 0.396). The CD4 cell count did not affect the incidence of infection (r = 0.16). When there was preoperative contamination, the incidence of infection in HIV-positive patients increased markedly (42%) compared with that in HIV-negative patients (11%; p = 0.084). Our results show that when no contamination has occurred implant surgery may be undertaken safely in HIV-positive patients.

Cauda equina syndrome

#### Summary points An understanding of cauda equina syndrome is important not only to orthopaedic surgeons and neurosurgeons but also to general practitioners, emergency department staff, and other specialists to whom these patients present. Recognition of the syndrome by all groups of clinicians is often delayed as it presents with bladder, bowel, and sexual problems, which are common complaints and have a variety of causes. Patients may not mention such symptoms because of embarrassment or because the onset is slow and insidious. Cauda equina syndrome is a clinical area that attracts a high risk of litigation. Although symptoms have poor predictive value on their own for the syndrome, it is important to document the nature and timing of bladder, bowel, and sexual symptoms (along with any associated clinical findings), particularly if they are new, especially in those with a history of back pain and associated leg pain, and to make a timely referral for appropriate investigation and expert treatment. This review aims to highlight cauda equina syndrome as a possible clinical diagnosis, review the evidence for an emergency surgical approach, and maintain an awareness of the medicolegal issues that surround the condition. Cauda equina syndrome results from the dysfunction of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. Such root dysfunction can cause a combination of clinical features, but the term cauda equina syndrome is used only when these include impairment of bladder, bowel, or sexual …

Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development

John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen, Edna Adan Ismail, Thaim Buya Kamara, Chris Lavy, Ganbold Lundeg, Nyengo C Mkandawire, Nakul P Raykar, Johanna N Riesel, Edgar Rodas‡, John Rose, Nobhojit Roy, Mark G Shrime, Richard Sullivan, Stéphane Verguet, David Watters, Thomas G Weiser, Iain H Wilson, Gavin Yamey, Winnie Yip

State of surgery in tropical Africa: a review.

This is a review of recently published literature on surgery in tropical Africa. It presents the current state of surgical need and surgical practice on the continent. We discuss the enormous burden of surgical pathology (as far as it is known) and the access to and acceptability of surgery. We also describe the available facilities in terms of equipment and manpower. The study looked at the effects of the human immunodeficiency virus, the role of traditional healers, anesthesia, and the economics of surgery. Medical training and research are discussed, as are medical migration out of Africa and the concept of task shifting, where surgical procedures are performed by others when surgeons are not available. It closes with recommendations for involvement and action in this area of great global need.

A national survey of musculoskeletal impairment in Rwanda: prevalence, causes and service implications.

Background Accurate information on the prevalence and causes of musculoskeletal impairment (MSI) is lacking in low income countries. We present a new survey methodology that is based on sound epidemiological principles and is linked to the World Health Organisations International Classification of Functioning. Methods Clusters were selected with probability proportionate to size. Households were selected within clusters through compact segment sampling. 105 clusters of 80 people (all ages) were included. All participants were screened for MSI by a physiotherapist and medical assistant. Possible cases plus a random sample of 10% of non-MSI cases were examined further to ascertain diagnosis, aetiology, quality of life, and treatment needs. Findings 6757 of 8368 enumerated individuals (80.8%) were screened. There were 352 cases, giving an overall prevalence for MSI of 5.2%. (95% CI 4.5–5.9) The prevalence of MSI increased with age and was similar in men and women. Extrapolating these estimates, there are approximately 488,000 MSI diagnoses in Rwanda. Only 8.2% of MSI cases were severe, while the majority were moderate (43.7%) or mild (46.3%). Diagnostic categories comprised 11.5% congenital, 31.3% trauma, 3.8% infection, 9.0% neurological, and 44.4% non-traumatic non infective acquired. The most common individual diagnoses were joint disease (13.3%), angular limb deformity (9.7%) and fracture mal- and non-union (7.2%). 96% of all cases required further treatment. Interpretation This survey demonstrates a large burden of MSI in Rwanda, which is mostly untreated. The survey methodology will be useful in other low income countries, to assist with planning services and monitoring trends.

Delay in skeletal maturity in Malawian children

The atlas of Greulich and Pyle for skeletal maturity and epiphyseal closure is widely used in many countries to assess skeletal age and to plan orthopaedic surgery. The data used to compile the atlas were collected from institutionalised American children in the 1950s. In order to determine whether the atlas was relevant to subSaharan Africa, we compared skeletal age, according to the atlas, with chronological age in 139 skeletally immature Malawian children and young adults with an age range from 1 year 11 months to 28 years 5 months. The height and weight of each patient were also measured in order to calculate the body mass index. The skeletal age of 119 patients (85.6%) was lower than the chronological age. The mean difference was 20.0+/-24.1 months (t-test, p = 0.0049), and the greatest difference 100 months. The atlas is thus inaccurate for this group of children. The body mass index in 131 patients was below the normal range of 20 to 25 kg/m2. The reasons for the low skeletal age in this group of children are discussed. Poor nutrition and chronic diseases such as malaria and diarrhoea which are endemic in Malawi are likely to be contributing factors. We did not find any correlation between the reduction in body mass index in our patients and the degree of retardation of skeletal age.

Club foot treatment in Malawi – a public health approach

Purpose. Malawi is a very poor country with a current population of 12 million people and very few orthopaedic surgeons or physiotherapists. An estimated 1125 babies are born per year with club foot. If these feet are not corrected early, then severe deformity can develop, requiring complex surgery. A task force was established to address this problem using locally available resources. Methods. A nationwide early manipulation programme was set up using the Ponseti technique, and a club foot clinic established in each of Malawis 25 health districts. One year later the clinics were reviewed. Results. Twenty out of the 25 clinics originally established were still active, and over one year had seen a total of 342 patients. Adequate records existed for 307 patients, of whom 193 were male and 114 female (ratio 1.7:1). A total of 175 patients had bilateral club foot and 132 were unilateral (ratio 1.3:1) giving a total of 482 club feet; 327 of the 482 feet were corrected to a plantigrade position. Most clinics had problems with supply of materials. Many patients failed to attend the full course of treatment. Conclusions. Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of children with club feet and their families. In a poor country with many demands on health funding many challenges remain. The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by many factors which need further research.