Global Surgical Ecosystems: A Need for Systems Strengthening

BackgroundAs surgery is gaining recognition as a critical component of universal health care worldwide, surgical communities have come together with unprecedented unity to advocate for systems to support surgical care. This community has long believed that much care could be performed in a cost-effective manner even in low resource settings, despite skepticism voiced by many in public health. To do so will require the development of new systems and re-vamping of old systems that are not effective. In the last five years, coalitions, expert panels, commissions, consortia and alliances have emerged to address these issues and there has been landmark success in advocacy with a new resolution at the 2015 World Health Assembly to include surgical care as a component of universal health coverage. It is critical to understand the ecosystem that constitutes the surgical environment. A surgical ecosystem could be described as a network of people, processes, and materials necessary for surgical services in the context of the facilities and environment in which it functions.MethodsWe describe components of a functioning surgical ecosystem in terms of administration, support staff and clinicians, and the necessary sub-systems for providing consumable materials such as anesthetic medication and suture and sterile instruments. Related systems that must be integrated are facilities and utilities such as electricity, lighting, plumbing and waste management and even laundry. But especially in low and middle income countries (LMICs) lack of any one of these may be rate-limiting. The World Health Organization (WHO) has developed situational analyses and checklists for first level district hospitals to identify missing elements.ConclusionsA siloed approach cannot solve a systems problem. However, to scale up rapidly and to develop and sustain quality standards, a holistic “ecosystem” approach, including local and global professional societies and advocacy organizations will need to become engaged

Gender, violence and resilience among Ugandan adolescents.

Resilience, commonly understood as the ability to maintain adaptive functioning in the face of adversity, has emerged as a salient entry point in the field of positive youth development. This study makes a unique contribution by exploring dimensions of resilience among adolescents in Uganda, examining associations between violence from different perpetrators and resilience, and testing whether sex moderates these relationships. Analyses are based on data from 3706 primary school students. Exploratory factor analysis (EFA) identified five factors underlying the construct of resilience: Emotional Support; Family Connectedness; School Connectedness; Social Assets; and Psychological Assets. We used regression analysis to investigate associations between these dependent variables, background characteristics, and experiences of violence (including exposure to intimate partner violence against female caregivers). Results reflect a complex relationship between violence and resilience, with patterns varying by perpetrator (e.g., teacher, peers, caregivers) and some evidence that the sex of the student moderates these dynamics. Overall, there is a consistently negative relationship between all violence measures and Psychological Assets. In addition, teacher violence is associated with lower resilience across factors and both caregiver violence and exposure to IPV are consistently associated with decreased Family Connectedness. These findings suggest that adolescents experiencing (and exposed to) violence from adults may be particularly vulnerable to internalizing and/or externalizing behaviors and withdrawal from the family. Findings point to preventing violence from teachers complemented with enhancing family relationships as promising avenues for resilience-strengthening interventions, and also emphasize the need to consider gendered strategies to ensure girls and boys benefit equally

IVUmed: A Nonprofit Model for Surgical Training in Low-Resource Countries

Background: Low- and middle-income countries (LMICs) face both training and infrastructural challenges for surgical care, particularly for specialty care, such as for urology. Practitioners charged with caring for these patients have few options for basic or advanced training. Objectives: IVUmed, a nonprofit organization, has for 20 years supported urological educational programs in 30 LMICs by coordinating a network of US and international academic and private providers, institutions, industry partners, and professional societies. Methods: IVUmed's motto, “Teach One, Reach Many” has emphasized a teach-the-teacher approach. Program partners, such as Hopital General de Grand Yoff in Dakar, Senegal, have advanced from little urological subspecialty availability to having the capacity to treat a wide range of conditions while also teaching surgeons from Senegal and neighboring countries. Conclusions: Long-term program commitments; effective communication; and a shared vision among the program site, the coordinating nongovernmental organization, and supporting organizations facilitate the development of thriving surgical teaching programs capable of serving local communities and conducting outreach training

Application of Laser Mass Spectrometry to Art and Archaeology

REMPI laser mass spectrometry is a combination of resonance enhanced multiphoton ionization spectroscopy and time of flight mass spectrometry, This technique enables the collection of mass specific optical spectra as well as of optically selected mass spectra. Analytes are jet-cooled by entrainment in a molecular beam, and this low temperature gas phase analysis has the benefit of excellent vibronic resolution. Utilizing this method, mass spectrometric analysis of historically relevant samples can be simplified and improved; Optical selection of targets eliminates the need for chromatography while knowledge of a target's gas phase spectroscopy allows for facile differentiation of molecules that are in the aqueous phase considered spectroscopically indistinguishable. These two factors allow smaller sample sizes than commercial MS instruments, which in turn will require less damage to objects of antiquity. We have explored methods to optimize REMPI laser mass spectrometry as an analytical tool to archaeology using theobromine and caffeine as molecular markers in Mesoamerican pottery, and are expanding this approach to the field of art to examine laccaic acid in shellacs

Violence against children and intimate partner violence against women: overlap and common contributing factors among caregiver-adolescent dyads.

BACKGROUND: Intimate partner violence against women (IPV) and violence against children (VAC) are both global epidemics with long-term health consequences. The vast majority of research to date focuses on either IPV or VAC, however the intersections between these types of violence are a growing area of global attention. A significant need exists for empirical research on the overlap of IPV and VAC, especially in contexts with particularly high rates of both types of violence. METHODS: This exploratory study includes secondary analysis of data from a cluster randomized controlled trial in Ugandan schools. Using baseline reports from a random sample of early adolescents attending school and their caregivers, this study uses a probability sample across all eligible schools of adolescent-caregiver dyads (n = 535). We categorized adolescent-caregiver dyads into four groups: those reporting VAC 'only', IPV 'only', both VAC and IPV, or 'no violence'. Two separate multinomial logistic regression models for male and female caregivers explored adolescent and caregiver characteristics associated with the VAC 'only', the IPV 'only', or the both VAC and IPV dyads, each compared to the 'no violence' dyad. RESULTS: One third of dyads reported both IPV and VAC and nearly 75% of dyads reported VAC or IPV. Dyads reporting IPV were more likely to also report VAC. Common contributing factors for female caregiver-adolescent dyads with both VAC and IPV include lower SES, less caregiver education, higher caregiver mental distress, more frequent caregiver alcohol use, and caregivers who report less emotional attachment to their intimate partner. Male caregiver-adolescent dyads with both VAC and IPV included caregivers with less emotional attachment to their intimate partner and more attitudes accepting VAC. CONCLUSIONS: Findings reveal a significant overlap of IPV and VAC and the importance for violence prevention and response programming to consider coordinated or integrated programming. Unique results for female and male caregivers highlight the importance of a gendered approach to addressing IPV and VAC intersections. TRIAL REGISTRATION: The trial was registered at clinicaltrials.gov, NCT01678846, on September 5, 2012

Epidemiologic investigation of immune-mediated polyradiculoneuropathy among abattoir workers exposed to porcine brain

Background In October 2007, a cluster of patients experiencing a novel polyradiculoneuropathy was identified at a pork abattoir (Plant A). Patients worked in the primary carcass processing area (warm room); the majority processed severed heads (head-table). An investigation was initiated to determine risk factors for illness. Methods and Results Symptoms of the reported patients were unlike previously described occupational associated illnesses. A case-control study was conducted at Plant A. A case was defined as evidence of symptoms of peripheral neuropathy and compatible electrodiagnostic testing in a pork abattoir worker. Two control groups were used - randomly selected non-ill warm-room workers (n = 49), and all non-ill head-table workers (n = 56). Consenting cases and controls were interviewed and blood and throat swabs were collected. The 26 largest U.S. pork abattoirs were surveyed to identify additional cases. Fifteen cases were identified at Plant A; illness onsets occurred during May 2004–November 2007. Median age was 32 years (range, 21–55 years). Cases were more likely than warm-room controls to have ever worked at the head-table (adjusted odds ratio [AOR], 6.6; 95% confidence interval [CI], 1.6–26.7), removed brains or removed muscle from the backs of heads (AOR, 10.3; 95% CI, 1.5–68.5), and worked within 0–10 feet of the brain removal operation (AOR, 9.9; 95% CI, 1.2–80.0). Associations remained when comparing head-table cases and head-table controls. Workers removed brains by using compressed air that liquefied brain and generated aerosolized droplets, exposing themselves and nearby workers. Eight additional cases were identified in the only two other abattoirs using this technique. The three abattoirs that used this technique have stopped brain removal, and no new cases have been reported after 24 months of follow up. Cases compared to controls had higher median interferon-gamma (IFNγ) levels (21.7 pg/ml; vs 14.8 pg/ml, P<0.001). Discussion This novel polyradiculoneuropathy was associated with removing porcine brains with compressed air. An autoimmune mechanism is supported by higher levels of IFNγ in cases than in controls consistent with other immune mediated illnesses occurring in association with neural tissue exposure. Abattoirs should not use compressed air to remove brains and should avoid procedures that aerosolize CNS tissue. This outbreak highlights the potential for respiratory or mucosal exposure to cause an immune-mediated illness in an occupational setting

Epidemiologic investigation of immune-mediated polyradiculoneuropathy among abattoir workers exposed to porcine brain

Background In October 2007, a cluster of patients experiencing a novel polyradiculoneuropathy was identified at a pork abattoir (Plant A). Patients worked in the primary carcass processing area (warm room); the majority processed severed heads (head-table). An investigation was initiated to determine risk factors for illness. Methods and Results Symptoms of the reported patients were unlike previously described occupational associated illnesses. A case-control study was conducted at Plant A. A case was defined as evidence of symptoms of peripheral neuropathy and compatible electrodiagnostic testing in a pork abattoir worker. Two control groups were used - randomly selected non-ill warm-room workers (n = 49), and all non-ill head-table workers (n = 56). Consenting cases and controls were interviewed and blood and throat swabs were collected. The 26 largest U.S. pork abattoirs were surveyed to identify additional cases. Fifteen cases were identified at Plant A; illness onsets occurred during May 2004–November 2007. Median age was 32 years (range, 21–55 years). Cases were more likely than warm-room controls to have ever worked at the head-table (adjusted odds ratio [AOR], 6.6; 95% confidence interval [CI], 1.6–26.7), removed brains or removed muscle from the backs of heads (AOR, 10.3; 95% CI, 1.5–68.5), and worked within 0–10 feet of the brain removal operation (AOR, 9.9; 95% CI, 1.2–80.0). Associations remained when comparing head-table cases and head-table controls. Workers removed brains by using compressed air that liquefied brain and generated aerosolized droplets, exposing themselves and nearby workers. Eight additional cases were identified in the only two other abattoirs using this technique. The three abattoirs that used this technique have stopped brain removal, and no new cases have been reported after 24 months of follow up. Cases compared to controls had higher median interferon-gamma (IFNγ) levels (21.7 pg/ml; vs 14.8 pg/ml, P<0.001). Discussion This novel polyradiculoneuropathy was associated with removing porcine brains with compressed air. An autoimmune mechanism is supported by higher levels of IFNγ in cases than in controls consistent with other immune mediated illnesses occurring in association with neural tissue exposure. Abattoirs should not use compressed air to remove brains and should avoid procedures that aerosolize CNS tissue. This outbreak highlights the potential for respiratory or mucosal exposure to cause an immune-mediated illness in an occupational setting

The Chemokine CXCL12 Is Essential for the Clearance of the Filaria Litomosoides sigmodontis in Resistant Mice

Litomosoides sigmodontis is a cause of filarial infection in rodents. Once infective larvae overcome the skin barrier, they enter the lymphatic system and then settle in the pleural cavity, causing soft tissue infection. The outcome of infection depends on the parasite's modulatory ability and also on the immune response of the infected host, which is influenced by its genetic background. The goal of this study was to determine whether host factors such as the chemokine axis CXCL12/CXCR4, which notably participates in the control of immune surveillance, can influence the outcome of the infection. We therefore set up comparative analyses of subcutaneous infection by L. sigmodontis in two inbred mouse strains with different outcomes: one susceptible strain (BALB/c) and one resistant strain (C57BL/6). We showed that rapid parasite clearance was associated with a L. sigmodontis-specific CXCL12-dependent cell response in C57BL/6 mice. CXCL12 was produced mainly by pleural mesothelial cells during infection. Conversely, the delayed parasite clearance in BALB/c mice was neither associated with an increase in CXCL12 levels nor with cell influx into the pleural cavity. Remarkably, interfering with the CXCL12/CXCR4 axis in both strains of mice delayed filarial development, as evidenced by the postponement of the fourth molting process. Furthermore, the in vitro growth of stage 4 filariae was favored by the addition of low amounts of CXCL12. The CXCL12/CXCR4 axis thus appears to have a dual effect on the L. sigmodontis life cycle: by acting as a host-cell restriction factor for infection, and as a growth factor for worms

The Problematization of Sexuality among Women Living with HIV and a New Feminist Approach for Understanding and Enhancing Women’s Sexual Lives

In the context of HIV, women’s sexual rights and sexual autonomy are important but frequently overlooked and violated. Guided by community voices, feminist theories, and qualitative empirical research, we reviewed two decades of global quantitative research on sexuality among women living with HIV. In the 32 studies we found, conducted in 25 countries and composed mostly of cis-gender heterosexual women, sexuality was narrowly constructed as sexual behaviours involving risk (namely, penetration) and physiological dysfunctions relating to HIV illness, with far less attention given to the fullness of sexual lives in context, including more&nbsp;positive and rewarding experiences such as satisfaction and pleasure. Findings suggest that women experience declines in sexual activity, function, satisfaction, and pleasure following HIV diagnosis, at least for some period. The extent of such declines, however, is varied, with numerous contextual forces shaping women’s sexual well-being. Clinical markers of HIV (e.g., viral load, CD4 cell count) poorly predicted sexual outcomes, interrupting widely held assumptions about sexuality for women with HIV. Instead, the effects of HIV-related stigma intersecting with inequities related to trauma, violence, intimate relations, substance use, poverty, aging, and other social and cultural conditions primarily influenced the ways in which women experienced and enacted their sexuality. However, studies framed through a medical lens tended to pathologize outcomes as individual “problems,” whereas others driven by a public health agenda remained primarily preoccupied with protecting the public from HIV. In light of these findings, we present a new feminist approach for research, policy, and practice toward understanding and enhancing women’s sexual lives—one that affirms sexual diversity; engages deeply with society, politics, and history; and is grounded in women’s sexual rights