The association between health financing and maternal and child health in Middle East and North Africa countries

Improving maternal and child health outcomes for women and children is a critical step to achieve the MDGs; however it requires sufficient funding to implement proven quality interventions. The aim of the study is to investigate the relationship between the different health care financing options cross the Middle East and North Africa “MENA countries and the maternal and child health outcomes. Our main argument is that: Can different health care financing strategies affect Maternal, Neonatal and Child health? If yes, How?. This study is based on a cross sectional analysis of twenty one states from MENA region between 2009 and 2013 exploring the three dimensions of the maternal and child health outcomes namely a) Infant mortality b) Maternal mortality and c) Child health. Correlation between financial and maternal and child health indicators as well as linear regressions was carried out to investigate the relationships between the maternal and child health indicators and health spending consequently health system financing strategy. The findings of this study indicate that more spending on health is highly associated with positive maternal and child health outcomes namely reduction in infant and child mortality. Our results also indicate that the improvements in government effectiveness in regards to government health spending is accompanied with higher maternal and child health outcomes. Thus, increasing government expenditures is likely to lead to better improvements of health outcomes if it is accompanied by the right policies and institutions, which was the case of the first group of countries in MENA region

The Diagnostic Value of Saline Infusion Sonohysterography Versus Hysteroscopy in Evaluation of Uterine Cavity in Patients with Infertility and Recurrent Pregnancy Loss

Objective:To evaluate the sensitivity, specificity, positive and negative predictive values of saline infusion sonohysterography (SIS) in patients with infertility and recurrent pregnancy loss in comparison with hysteroscopy.Materials and methods: One-hundred sixty one women with infertility or recurrent pregnancy loss (RPL) were evaluated by SIS and hysteroscopy. The uterine cavity was inspected for irregularities as synechiae, polyps and submucous myomas, as well as uterine malformations. Results:The mean age of patients was 35.32±6.43. Endometrial polyps were equally detected by both methods in the two groups. Submucous fibroids were more detected by SIS while intrauterine adhesions and congenital anomalies were more detected by hysteroscopy in both groups. The sensitivity, specificity, positive and negative predictive values of SIS in patients with infertility was higher than those with RPL (84.3 and 75%, 94.1 and 96.7%, 93.1 and 92.5, 74.4 and 67.9% respectively).Conclusion:Hysteroscopy is superior to SIS in diagnosis of intracavitary abnormalities. However, saline infusion sonohysterography has the advantages of being non-invasive, cheap, affordable, shorter duration and accurate method for uterine cavity evaluation

Three-dimensional transvaginal ultrasound: clinical implementation in assessing uterine cavity

Background: Three-dimensional transvaginal ultrasonography (3D TVS) represents a new technique of imaging and provides a unique diagnostic tool for non-invasive examination of the uterine morphology and diagnosis of congenital uterine anomalies. In this study the clinical value of 3D TVS in diagnosis of uterine cavity abnormalities were evaluated.Methods: A prospective of diagnostic accuracy study included 226 patients with various clinical presentations; infertility, recurrent pregnancy loss, menstrual disorders and post-menopausal bleeding with suspected uterine cavity lesions or abnormality on two-dimensional (2D) TVS or hysterosalpingography (HSG). After taking consent, all patients were subjected to history taking, clinical examination, 3D TVS evaluation, magnetic resonance imaging (MRI) and finally endoscopic examination.Results: The 3D has 98% accuracy in infertile women in comparison to 87% for MRI. While with recurrent pregnancy loss, Concordance was 96% correct for 3D and 78% for MRI. The women with abnormal uterine bleeding, the accuracy of 3D was 100%, while with MRI was 74%. The sensitivity of 3D TVS was 97.8% and 100% specificity, positive and negative predictive value. While the sensitivity, specificity, positive and negative predictive values for MRI were 89.3%, 64%, 70.4% and 86.3% respectively.Conclusions: 3D TVS appears to be extremely accurate, less expensive and a rapid examination for the diagnosis and classification of uterine anomalies, more than MRI. Thus it may become the only mandatory step in the assessment of the uterine cavity

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Islamism and the state after the Arab uprisings: Between people power and state power

The authors would like to thank the Arts and Humanities Research Council for facilitating the research for this article through their support of the research network People Power versus State Power of the Centre for the Advanced Study of the Arab World.This paper examines the trajectories of different Islamist trends in the light of the Arab uprisings. It proposes a distinction between statist and non-statist Islamism to help understand the multiplicity of interactions between Islamists and the state, particularly after 2011. It is outlined how statist Islamists (Islamist parties principally) can contribute to the stabilization and democratization of the state when their interactions with other social and political actors facilitate consensus building in national politics. By contrast when these interactions are conflictual, it has a detrimental impact on both the statist Islamists, and the possibility of democratic politics at the national level. Non statist-Islamists (from quietist salafi to armed jihadi) who prioritize the religious community over national politics are directly impacted by the interactions between statist Islamists and the state, and generally tend to benefit from the failure to build a consensus over democratic national politics. Far more than nationally-grounded statist Islamists, non-statist Islamists shape and are shaped by the regional dynamics on the Arab uprisings and the international and transnational relations between the different countries and conflict areas of the Middle East. The Arab uprisings and their aftermath reshaped pre-existing national and international dynamics of confrontation and collaboration between Islamists and the state, and between statist and non-statists Islamists, for better (Tunisia) and for worse (Egypt).PostprintPeer reviewe

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

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

Background 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&lt;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&lt;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