Management of Burns in Gaza-Strip A Multi-center Clinical Audit

A combined prospective and retrospective study was conducted in the ERs of Al-Shifa, Nasser Medical Complex and European Gaza hospitals. Two structured questionnaires were used to collect the management of burn according to the Palestinian management protocol. This study found that from the 147 cases that came to the ER, 37.6% underwent ABCDE approach and 87.8% (n=129/147) received sterile dressings. Background: Burns is a global public health problem and appropriate intervention will decrease morbidity and mortality. This study aimed to evaluate the management of burns in the emergency room (ER), burns units and intensive care units (ICU) of the Gaza-Strip. Objectives: To evaluate the management of burns in the ER, burns unit and ICU in terms of following ABCDE approach, using sterile dressings, giving fluid resuscitation, antibiotics, ranitidine and undergoing physiotherapy. Methods: A prospective study evaluated the management of patients presenting with burns injuries to the ER between the period 22nd July to 20 August 2018, and retrospectively, management of patients was evaluated, who were admitted to the burns units and to ICU between 1st January 2017 and 30th July 2018 at Al-Shifa Hospital and Nasser Medical Complex. The Palestinian management protocol was used for evaluation. A total of 428 patients were identified to have burns injuries during the study period. Of these, 142 were excluded, 108 due to missing files and 34 files had poor documentation (no documentation of medication or assessments). Included were 147 patients admitted to ER, 122 on the burns unit and 17 on the ICU. Results: In the ER, 57.1% (n=84/147) of patients were male, with a mean age of 15.4±14.1. Of the 147 cases, 17.7% (n=26/147) were major burns, which included more than 10% total body surface area burned (TBSA). Of these, 37.6% underwent ABCDE approach and 87.8% (n=129/147) received sterile dressings. From the 122 patients admitted to the burns unit, 59.8% (n=73) were male with a mean age of 11.4±14.6 years. From these, 47.5% (n=58/122) underwent fluid resuscitation, 97.5% (n=119/122) received antibiotics, 17.2% (n=21/122) received ranitidine and 56.6% (n=69/122) underwent physiotherapy. Out of the 17 patients admitted to ICU, 76.5% (n=13/17) were male, with a mean age of 19.2±12.8 years. All of these patients received prophylactic antibiotics, 58.8% (n=10/17) had endotracheal intubation, 5.9% (n=1/17) underwent central venous pressure measurement (CVP), 23.5% (n=4/17) had ABG tested and 88.2% (n=15/17) kidney function tests (KFT), and 64.7% (n=11/17) received ranitidine. No patient had a chest X-Ray (CXR) or carbon monoxide (CO) level done. From the ICU patients, 17.6% (n=3/17) benefitted from physiotherapy, and 35.3% (n=6/17) Conclusion: The findings of this study demonstrate poor adherence to guidelines in some points, such as patients presenting with major burns, who should all benefit from the ABCDE approach, but less than 40% of patients actually did and antibiotics, which should only be prescribed when indicated, were given to nearly all patients admitted to the burns unit or ICU. Efforts are required to improve staff practices with burn injuries

Quality of Pain Relief Provided in the Emergency Room (ER) for Patients with Acute Abdominal Pain A Prospective Clinical Audit

A prospective study was conducted in the ERs of Al-Shifa, Indonesian and European Gaza hospitals, a structured questionnaire was used to collect characteristics of pain and its management. Pain intensity was recorded at different intervals using a 10-point numerical rating scale. This study found that patients attended to ER with a mean pain score of 8.3±1.4 and they left with a mean pain score of 4.6±3.5. burns. Background: Acute abdominal pain is the most common cause of surgical consultations in the ER and the most common cause of non-trauma related admissions. Little is known about pain management in Gaza Strip hospitals. Therefore, this study assesses whether patients presenting with acute abdominal pain received adequate analgesia, compared to the Royal College of Emergency Medicine Guidelines. Objectives: To assess pain management in the ER in terms of the prescription practice of pain-relieving medications, pain progression from arrival till disposition and adequacy of analgesics provided. Methodology: A prospective-observational study was conducted in the ERs of three Gaza Strip hospitals, representing three distinct geographical areas, from 30th July till 30th August. All Patients above 18 years old, presented to the ER with acute abdominal pain, with no history of analgesia intake before their hospital visit were included. Data was collected by nine trained interviewers through a structured questionnaire. Pain was quantified by the patients by a 10-point numerical rating scale. This was done on arrival as well as at 30 and 60 minutes after receipt of analgesia and at discharge. Verbal consent was obtained from the patients. Approval had been obtained from the Directorate General of Human Resources Development before data collection. Data were analyzed via SPSS and are presented as mean scores ± standard deviations as well as in total numbers and percentages. Results: A total of 157 patients were included, 77 (49%) were males and the mean age was 39.8+15.4 years. Furthermore, 78 (49.7%) were from Hospital A, 52 (33.1%) from Hospital B and 27 (17.2%) from Hospital C. The sample included 100 (63.7%) patients with a provisional diagnosis of renal colic, 17 (10.8%) with biliary colic, 13 (8.3%) with appendicitis, 9 (5.7%) with intestinal obstruction and 18 (11.4%) other diagnoses. A total of 29 patients (18.5%) did not receive any analgesia in the ER. Of the 128 patients (81.5%), who received analgesics, 115 (89.8%) had non-steroidals while 13 (10.1%) received opioids. Opioids were adequately titrated in all patients and no circulatory instability occurred. The mean pain score on arrival was 8.3±1.4, while it was 7.1±3.6 30 minutes later, 6.6±4.2 after 60 minutes and 4.6±3.5 on discharge. Conclusion: Although pain relief was given and experienced pain decreased for most patients, but only seven patients (4.4%) were completely pain-free on discharge. Generally, patients with intense pain were quickly given analgesics. Hence, efforts should be focused on patients suffering moderate or mild pain to also receive adequate pain relief in the ER. Agreed local guidelines and training of staff could also facilitate this process

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review

To estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic. Systematic review. Two parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence. Publication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed. A total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7). COVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research