Drake G. LeBrun

Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.

BACKGROUND Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure. METHODS The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity. RESULTS Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries. CONCLUSION The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

Measuring global surgical disparities: a survey of surgical and anesthesia infrastructure in Bangladesh.

BackgroundSurgically treatable diseases weigh heavily on the lives of people in resource-poor countries. Though global surgical disparities are increasingly recognized as a public health priority, the extent of these disparities is unknown because of a lack of data. The present study sought to measure surgical and anesthesia infrastructure in Bangladesh as part of an international study assessing surgical and anesthesia capacity in low income nations.MethodsA comprehensive survey tool was administered via convenience sampling at one public district hospital and one public tertiary care hospital in each of the seven administrative divisions of Bangladesh.ResultsThere are an estimated 1,200 obstetricians, 2,615 general and subspecialist surgeons, and 850 anesthesiologists in Bangladesh. These numbers correspond to 0.24 surgical providers per 10,000 people and 0.05 anesthesiologists per 10,000 people. Surveyed hospitals performed a large number of operations annually despite having minimal clinical human resources and inadequate physical infrastructure. Shortages in equipment and/or essential medicines were reported at all hospitals and these shortages were particularly severe at the district hospital level.ConclusionsIn order to meet the immense demand for surgical care in Bangladesh, public hospitals must address critical shortages in skilled human resources, inadequate physical infrastructure, and low availability of equipment and essential medications. This study identified numerous areas in which the international community can play a vital role in increasing surgical and anesthesia capacity in Bangladesh and ensuring safe surgery for all in the country.

Surgical and Anesthesia Capacity in Bolivian Public Hospitals: Results from a National Hospital Survey

BackgroundUnderdeveloped nations suffer from significant deficiencies in surgical and anesthesia care. Although surgical inequities are a pressing issue internationally, the extent of these inequities is unknown due to a lack of data. The aim of this study was to assess surgical and anesthesia capacity in Bolivia as part of a multinational study assessing surgical and anesthesia infrastructure in Africa, Latin America, and South Asia.MethodsA standardized survey tool was used to obtain national-level health-care data at the Bolivian Ministry of Health. Hospital-specific data were obtained through interviews with key administrators and providers at 18 public basic and general hospitals in Bolivia.ResultsThere are 1,270 obstetrician/gynecologists and 1,807 surgeons in Bolivia. In contrast, there are 500 anesthesiologists, placing a large anesthesia burden on the country. Basic hospitals and general hospitals performed an average of 730 and 2,858 operations per year, respectively. One basic hospital was unable to perform any surgeries due to a lack of surgical manpower. All but two hospitals reported some lack of infrastructure, equipment, or pharmaceutical capacity. The ability to collect health outcomes was inconsistent in most hospitals.ConclusionsSurgical capacity varies throughout Bolivia. There are relatively large numbers of surgery providers but an insufficient number of anesthesiologists, suggesting a specific need for further development in anesthesia. Though there are many areas of strength within the Bolivian public health-care system, this survey identified several areas to which national policy and international collaboration can contribute in order to more adequately address major causes of surgical morbidity and mortality.

A Geospatial Evaluation of Timely Access to Surgical Care in Seven Countries/Evaluation Geospatiale De L'acces En Temps Voulu Aux Soins Chirurgicaux Dans Sept pays/Una Evaluacion Geoespacial del Acceso Oportuno a la Atencion Quirurgica En Siete Paises

Abstract: Objective To assess the consistent availability of basic surgical resources at selected facilities in seven countries. Methods In 2010–2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao Peoples Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital’s catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. Findings Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. Conclusion Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Predictors of Wound Complications following Radiation and Surgical Resection of Soft Tissue Sarcomas

Wound complications represent a major source of morbidity in patients undergoing radiation therapy (RT) and surgical resection of soft tissue sarcomas (STS). We investigated whether factors related to RT, surgery, patient comorbidities, and tumor histopathology predict the development of wound complications. An observational study of patients who underwent STS resection and RT was performed. The primary outcome was the occurrence of any wound complication up to four months postoperatively. Significant predictors of wound complications were identified using multivariable logistic regression. Sixty-five patients representing 67 cases of STS were identified. Median age was 59 years (range 22–90) and 34 (52%) patients were female. The rates of major wound complications and any wound complications were 21% and 33%, respectively. After adjusting for radiation timing, diabetes (OR 9.6; 95% CI 1.4–64.8; P = 0.02), grade ≥2 radiation dermatitis (OR 4.8; 95% CI 1.2–19.2; P = 0.03), and the use of 3D conformal RT (OR 4.6; 95% CI 1.1–20.0; P = 0.04) were associated with an increased risk of any wound complication on multivariable analysis. These data suggest that radiation dermatitis and radiation modality are predictors of wound complications in patients with STS.

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

BackgroundHip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent.DiscussionThe license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort.ConclusionsA medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former.

Endoscopic Thermal Fasciotomy for Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome is an activity-induced condition that occurs when intracompartmental pressures within an osteofascial envelope increase during exercise, leading to reversible ischemic symptoms such as pain, cramping, numbness, or weakness. Nonoperative treatment options for this condition have shown limited success and are often undesirable for the patient given the requirement for activity modification. Traditional surgical treatment options involving open or subcutaneous fasciotomies have more favorable results, but these techniques are associated with significant morbidity. Endoscopically assisted fasciotomy techniques afford the advantages of being minimally invasive, providing excellent visualization, and allowing accelerated rehabilitation. The purpose of this article is to describe a technique for performing endoscopically assisted fasciotomies for chronic exertional compartment syndrome of the lower leg using an entirely endoscopic thermal ablating device. The endoscopic thermal fasciotomy technique is associated with minimal morbidity, ensures excellent hemostasis, and affords an early return to sports.

Nonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment success

BACKGROUND Osteochondritis dissecans (OCD) of the capitellum is a rare but potentially debilitating condition. We sought to determine the healing potential of stable capitellar OCD treated nonoperatively, as well as factors predictive of successful nonoperative management. METHODS We performed a retrospective review of patients younger than 19 years who presented with stable OCD of the capitellum and were treated nonoperatively for a minimum of 2 months. The average clinical and radiographic follow-up period was 12.1 months (range, 3.1-63.7 months). A multivariable logistic regression model was used to determine independent predictors of healing. RESULTS The study included 89 patients (93 elbows), including 49 male patients (55%); the mean age was 12.7 years (range, 8.9-18.6 years). Of the 93 elbows, 50 (53.8%) had successfully healed at a mean of 8.3 months. The symptom duration was significantly shorter in the healing group than the nonhealing group (5.3 ± 4.4 months vs 8.8 ± 9.0 months, P = .02). There were no significant differences in age, physeal status, sex, hand dominance, or sport. Hefti stage I lesions had a higher rate of healing (64.3%) than stage II (31.4%, P = .004), as did OCDs without cyst-like lesions (CLLs, 62.0%) compared with those with CLLs (20.8%, P = .001). The normalized lesion area was significantly larger in the nonhealing group (26.9% vs 18.6%, P < .001). A smaller normalized area and the absence of CLLs were independent predictors of healing. CONCLUSIONS Over half of stable capitellar OCD lesions have the potential to heal with activity restriction. Smaller lesions without CLLs are more likely to heal with nonoperative treatment.

Clinical and Radiographic Predictors of Acetabular Cartilage Lesions in Adolescents Undergoing Hip Arthroscopy

Background: Acetabular cartilage lesions are a known cause of poor outcomes after hip arthroscopy and are seen regularly among adolescents. However, studies identifying preoperative factors predictive of acetabular cartilage lesions have been limited to adult populations. Purpose: To assess clinical and radiographic predictors of acetabular cartilage lesions in a large cohort of adolescents undergoing hip arthroscopy. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for idiopathic femoroacetabular impingement or acetabular labral tears at a children’s hospital were reviewed. Demographic predictors were analyzed by use of univariate logistic regression with generalized estimating equations. A matched case-control analysis was subsequently performed to identify radiographic predictors of acetabular cartilage lesions through use of univariate and multivariable conditional logistic regression. Results: Four hundred two patients (446 hips) undergoing hip arthroscopy between 2010 and 2015 were analyzed. Median age was 16.7 years (range, 13.6-19.0) and 72% of patients were female. Ninety-five hips (21%) were found to have an acetabular cartilage lesion at the time of arthroscopic surgery. Age (odds ratio [OR], 1.7; 95% CI, 1.4-2.1), male sex (OR, 2.5; 95% CI, 1.7-5.0), and body mass index (OR, 1.07; 95% CI, 1.01-1.14) were found to be predictive of intraoperative acetabular cartilage lesions. In the matched case-control analysis, femoral alpha angle as calculated on a Dunn lateral radiograph was independently predictive of an intraoperative acetabular cartilage lesion (OR, 1.8; 95% CI, 1.2-2.6). Additionally, the presence of a crossover sign was independently associated with a decreased odds of an acetabular cartilage lesion (OR, 0.3; 95% CI, 0.1-0.7). On multivariate analysis, alpha angle (Dunn lateral) (OR, 2.0; 95% CI, 1.3-3.1) and crossover sign (OR, 0.2; 95% CI, 0.1-0.7) remained independently associated with the presence of an acetabular cartilage lesion. The presence of an acetabular labral tear was not predictive of an associated cartilage lesion (OR, 1.17; 95% CI, 0.39-3.47; P = .78). Conclusion: In an adolescent population undergoing hip arthroscopy, older age, male sex, and higher body mass index were predictive of acetabular cartilage lesions. From an imaging standpoint, increased alpha angle increased the likelihood of an acetabular cartilage lesion whereas the presence of a crossover sign decreased this likelihood. Predicting the presence of an acetabular cartilage lesion is important when considering a hip arthroscopy procedure to facilitate preoperative planning and to more accurately set patient expectations.

Predictors of healthcare seeking delays among children with chronic musculoskeletal disorders in Nepal

Background: Healthcare seeking behaviors among children with musculoskeletal disorders are poorly understood. We sought to analyze healthcare seeking delays among children with chronic musculoskeletal conditions in Nepal and identify predictors of clinically significant delays. Methods: A cross-sectional study was conducted at a large pediatric musculoskeletal rehabilitation center in Nepal. Baseline sociodemographic data and healthcare seeking behaviors were assessed via interviews with 75 randomly selected caregivers. Delays of at least 3 months between disease recognition and presentation to a health worker were considered clinically significant. Predictors of significant delay were assessed via multivariable logistic regression. Results: Clubfoot was the most common condition seen in the study sample (N = 33; 37%). Mean and median presentation delays were 33 months and 14 months, respectively. Sixty-seven percent of children were delayed at least 3 months and 40% were delayed at least 2 years. Caregiver occupation in agriculture or unskilled labor was associated with an increased risk of delayed presentation (adjusted OR = 4.05; 95% CI: 1.36–12.09). Conclusions: Children with chronic musculoskeletal disorders in Nepal face significant delays in accessing healthcare. This poses a major clinical problem as the delayed diagnosis and treatment of childhood musculoskeletal disorders can complicate management options and decrease long-term quality of life.