Scaling Safe Circumcisions in Communities

Male circumcision (MC), although a common and simple procedure, is not available to a majority of the population as a safe, sterile intervention. The convincing evidence of the protective role of circumcision towards the spread of STDs (particularly HIV) led to the establishment of voluntary, adult male circumcision programmes in high-HIV-burden countries. In low- and middle-income Muslim countries, where the need for circumcision is high, there is an evident gap in access to, and delivery of, this procedure. Large-scale programmes aimed at circumcising male babies in settings where circumcision is a religious requirement, as opposed to a medical indication, have not been established. This chapter would draw upon current guidelines and literature, review existing programmes that have attempted to establish community-based safe circumcision initiatives and discuss strategies for sustainable scale-up to meet this huge public health need. We believe it is important to translate existing clinical knowledge into a population-based healthcare intervention

Who is pirating medical literature? A bibliometric review of 28 million Sci-Hub downloads.

We aimed to define the proportion of downloads on Sci-Hub that are medical in nature and to consider these data at the national level, evaluating the relation between density of medical literature downloads and scientific output, national income classifications, and indicators of internet penetrance

Clinical skills in undergraduate program and Curricular change – does it make a difference?

Background Clinical Skills Laboratory (CSL) was established at Foundation University Medical College (FUMC) in year 2009 with the introduction of integrated modular teaching program. A structured integrated curriculum was introduced from the Class of year 2013 for learning of clinical skills at CSL. This study was conducted to evaluate the effect of introducing the new curriculum on student’s performance in CSL. Methods A comparative analytical study was conducted. The OSCE scores of group A (Class of year 2011) were compared with group B (Class of 2013). Data collection tool was institutional checklist. The OSCE stations were of General Physical Examination (GPE), history taking, systemic examination of Gastrointestinal tract and communication skills. Reliability of the scores was estimated through Cronbach α. Mean scores of the two groups were compared using the independent sample t test and Mann Whitney U-test. Chi-square test was used to compare variables (years, gender and educational background). Comparison of student scores at different components of OSCE using Analysis of Variance (ANOVA) was done.   Results Reliability of scores was 0.65 for group B and 0.52 for group A. comparison of overall scores of the two groups reflected improved performance in the group B (p 0.001). Comparison of scores at different components of OSCE using ANOVA also reflected better performance of group B (p<0.01). OSCE scores of both the groups were also correlated for gender and educational background. No difference was found in the two groups on the basis of gender and educational background. Conclusion To enhance the value of clinical skills training and to make it more effective, skill lab curriculum must be structured and integrated within the undergraduate curriculum. Key words;Clinical skills laboratory, undergraduate integrated curriculum, clinical skills training&nbsp

Maximising access to timely trauma care across population of Karachi and its districts: A geospatial approach to develop a trauma care network

Objectives: To develop and propose a cost-effective trauma care network for Karachi, Pakistan, by calculating maximum timely trauma care (TTC) coverage achieved with the addition of potential designated private and public level 1 and level 2 trauma centres (TCs). Setting: A lower middle-income country metropolis, Karachi is Pakistan\u27s largest city with a population of 16 million and a total of 56 hospitals as per government registry data. Participants: 41 potential TCs selected using a two-level, contextually-relevant TC designation criteria adapted from various international guidelines. Primary and secondary outcome measures: Maximum TTC coverage achievable with the addition of potential TCs. Proposed trauma care network composition to achieve maximum TTC coverage. Results: Coverage with five public level 1 hospitals alone is 74.4%. Marginal benefit with stepwise addition of five potential private level 1 TCs, four public level 2 TCs and two private level 2 TCs is 12.2%, 7.1% and 3.1%, respectively. Maximum possible TTC coverage is 96.7%. Poorest coverage with the proposed 16 hospital network is noted in Malir district while 100% coverage is achieved in the centrally located South, Central and East districts. Conclusion: Addition of private level 1 and private and public level 2 hospitals to the trauma care network is necessary. Implementation of the proposed trauma care network requires strong stewardship from the government and coordinated effort of multiple stakeholders is needed to ensure standard TC designation. The study exhibits an effective method to scientifically plan and develop a cost-effective trauma system which can be applied in other resource-limited geographical area

Implementation of an infant male circumcision programme, Pakistan

Objective: To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan.Methods: Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1-92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression.Findings: Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1-30 days of age: 31-60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31-3.15; 61-92 days: aOR: 2.14; 95% CI: 1.13-4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant).Conclusion: Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans:a policy content analysis

Objective While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies. Design We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia. Results Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed € human resources and training' and € infrastructure', four addressed € service delivery', three addressed € governance and financing', two included € research, evaluation and quality improvement', and one NSOAP addressed € equipment and supplies' and € advocacy and awareness'. Conclusions Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.</p

Access and Financial Burden for Patients Seeking Essential Surgical Care in Pakistan

Background: Pakistan is a lower middle-income country in South Asia with a population of over 220 million. With the recent development of national health programs focusing on surgical care, two areas of high priority for research and policy are access and financial risk protection related to surgery. This is the first study in Pakistan to nationally assess geographic access and expenditures for patients undergoing surgery. Methods: This is a cross-sectional study of patients undergoing laparotomy, cesarean section, and surgical management of a fracture at public tertiary care hospitals across the country. A validated financial risk protection tool was adapted for our study to collect data on the socio-economic characteristics of patients, geographic access, and out-of-pocket expenditure. Results: A total of 526 patients were surveyed at 13 public hospitals. 73.8% of patients had 2-hour access to the facility where they underwent their respective surgical procedures. A majority (53%) of patients were poor at baseline, and 79.5% and 70.3% of patients experienced catastrophic health expenditure and impoverishing health expenditure, respectively. Discussion: A substantial number of patients face long travel times to access essential surgical care and face a high percentage of impoverishing health expenditure and catastrophic health expenditure during this process. This study provides valuable baseline data to health policymakers for reform efforts that are underway. Conclusions: Strengthening surgical infrastructure and services in the existing network of public sector first-level facilities has the potential to dramatically improve emergency and essential surgical care across the country

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