Humanitarian surgeries are performed in low- and middle-income countries (LMICs) to help address untreated surgical disease. Post-operative follow-up is challenging but crucial to monitor recovery, ...detect complications, and assess outcomes. Establishing a comprehensive protocol in partnership with local healthcare personnel may improve patient adherence.
A retrospective review of missions from 2011 to 2019 to Sierra Leone by the International Surgical Health Initiative (ISHI). In 2017, a protocol was established with the following key elements: patient education, community leader recruitment, and logistical support. Patient demographics and follow-up rates were compared between groups.
In total, 396 patients underwent operations from 2011 to 2019. Most patients were male (84%), mean age 40 ± 14 years, and primarily underwent hernia repair (68%). Initially, follow-up rates of 205 patients were <5%; after protocol implementation, follow-up rates among 128 patients who received operations increased to 96–97%.
A community-based follow-up protocol in Sierra Leone yielded high patient adherence. The protocol emphasizes context-appropriate patient education and community engagement. Protocols are feasible and generalizable to patients cared for by international and hosting surgical teams.
•Humanitarian non-governmental organizations (NGOs) help support LMIC providers by providing free surgeries.•Overall outcomes are underreported and are challenging to obtain secondary to difficult follow-up.•Complex barriers to follow-up adherence are addressed by a comprehensive protocol.•Key protocol components include a collaborative framework with local healthcare workers.•Follow-up rates have a demonstrated increase in Sierra Leone secondary to an intentional protocol.
Abstract
BACKGROUND
The role of enhanced recovery after surgery (ERAS) pathways implementation has not been previously explored in adult deformity patients.
OBJECTIVE
To determine the impact of ERAS ...pathways implementation in adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis on postoperative outcome, opioid consumption, and unplanned readmission rates.
METHODS
In this retrospective single-center study, we included 124 consecutive patients who underwent open thoraco-lumbar-pelvic fusion from October 2016 to February 2019 for degenerative scoliosis. Primary outcomes consisted of postoperative supplementary opioid consumption in morphine equivalent dose (MED), postoperative complications, and readmission rates within the postoperative 90-d window.
RESULTS
There were 67 patients in the ERAS group, and 57 patients served as pre-ERAS controls. Average patient age was 69 yr. The groups had comparable demographic and intraoperative variables. ERAS patients had a significantly lower rate of postoperative supplemental opioid consumption (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001).
CONCLUSION
A comprehensive multidisciplinary approach to complex spine surgery can reduce opioid intake, postoperative urinary retention and severe constipation, and unplanned 90-d readmissions in the elderly adult population.
Graphical Abstract
Graphical Abstract
Leishmaniasis, a neglected tropical disease, is caused by the intracellular protozoan parasite Leishmania. Upon its transmission through a sandfly bite, Leishmania binds and enters host phagocytic ...cells, ultimately resulting in a cutaneous or visceral form of the disease. The limited therapeutics available for leishmaniasis, in combination with this parasite's techniques to evade the host immune system, call for exploring various methods to target this infection. To this end, our laboratory has been characterizing how Leishmania is internalized by phagocytic cells through the activation of multiple host cell signaling pathways. This protocol, which we use routinely for our experiments, delineates how to infect mammalian macrophages with either promastigote or amastigote forms of the Leishmania parasite. Subsequently, the number of intracellular parasites, external parasites, and macrophages can be quantified using immunofluorescence microscopy and semi-automated analysis protocols. Studying the pathways that underlie Leishmania uptake by phagocytes will not only improve our understanding of these host-pathogen interactions but may also provide a foundation for discovering additional treatments for leishmaniasis. Key features • This protocol visualizes and quantifies multiple intracellular forms of Leishmania. • It offers flexibility at various points for researchers to introduce modifications according to their study needs.Leishmaniasis, a neglected tropical disease, is caused by the intracellular protozoan parasite Leishmania. Upon its transmission through a sandfly bite, Leishmania binds and enters host phagocytic cells, ultimately resulting in a cutaneous or visceral form of the disease. The limited therapeutics available for leishmaniasis, in combination with this parasite's techniques to evade the host immune system, call for exploring various methods to target this infection. To this end, our laboratory has been characterizing how Leishmania is internalized by phagocytic cells through the activation of multiple host cell signaling pathways. This protocol, which we use routinely for our experiments, delineates how to infect mammalian macrophages with either promastigote or amastigote forms of the Leishmania parasite. Subsequently, the number of intracellular parasites, external parasites, and macrophages can be quantified using immunofluorescence microscopy and semi-automated analysis protocols. Studying the pathways that underlie Leishmania uptake by phagocytes will not only improve our understanding of these host-pathogen interactions but may also provide a foundation for discovering additional treatments for leishmaniasis. Key features • This protocol visualizes and quantifies multiple intracellular forms of Leishmania. • It offers flexibility at various points for researchers to introduce modifications according to their study needs.
It is of paramount importance that the United States (U.S.) physician and surgical workforce reflects its changing population demographics. The authors characterized factors contributing to ...graduating medical students’ decision to pursue a residency in Neurosurgery to assess opportunities for recruitment and retainment of graduates interested in working with underserved populations.
Data from the Association of American Medical Colleges (AAMC) Student Record System (SRS), and the AAMC Graduation Questionnaire (GQ) were collected on a national cohort of U.S. medical students from 2012 through 2017. Data including self-reported sex, race/ethnicity, age at matriculation, degree program, intention to practice in underserved area, total debt, scholarships, volunteer activities and medical electives was analyzed using chi-squared tests and multivariate logistic regression models.
The study included 48,096 graduating medical students surveyed by GQ and SRS, 607 (1.26%) of whom reported an intention to pursue Neurosurgery (Neurosurgery cohort). Compared to students pursuing other specialties, the Neurosurgery cohort had fewer students identify as female (18.95% vs. 48.18%, p < 0.001), and report an intention to work with underserved populations (11.37% vs. 26.37%, p < 0.001). In addition, Black/African-American students were significantly more like to indicate intention to pursue Neurosurgery compared to White students (aOR=1.51, 95% CI:1.01–2.24). Moreover, within the Neurosurgery cohort, Black/African-American (aOR=7.66, 95% CI:2.87–20.45), Hispanic (aOR=4.50, 95% CI:1.40–14.51) and female students (aOR=2.44, 95% CI:1.16–5.12) were more likely to report an intention to practice in underserved urban and rural areas, compared to their peers.
Our study identified several key demographic and academic factors influencing intention to pursue a neurosurgical career, and work with underserved populations. Our data provides an opportunity for further discussions on the residency selection process and seeks to empower residency programs to diversify the neurosurgical workforce, tackle health disparities and improve patient care for the entire US population.
•Addressing health disparities is now at the forefront of Neurosurgery.•Male sex, Black race, and research are predictors of intent to pursue Neurosurgery.•Female, Black and Hispanic students are more likely to IWUP in Neurosurgery.•Innovative strategies to improve residency recruitment and retention are warranted.•Increasing Neurosurgery workforce diversity will take multiple approaches.
INTRODUCTION Smoking status and opioid medication intake have been associated with increased opioid consumption and suboptimal functional outcomes after spine surgery. However, the interaction ...between smoking and preoperative opioid intake has not been studied in the elderly. METHODS The records of 536 consecutive patients aged more than 65 years who underwent elective spinal surgery between November 2014 and August 2017 at a single institution were reviewed. Data was collected prospectively in a spine registry and included demographic information, smoking status, and procedural details. Primary outcomes included rates of preoperative opioid consumption and postoperative hospital length of stay and complications. RESULTS Males were more likely to be smokers than females (45.70% vs 32.91%; P < .001), whereas females were more likely to take opioid analgesics preoperatively (49.15% vs 40.40%; P = .022). Women with a history of smoking were more likely to have increased preoperative opioid consumption compared to those with no history of smoking (63.64% vs. 42.04%; P < .001). Such a relationship was not found in men. Subgroups analysis of female patients with a history of tobacco use comparing current and former smoker status, showed that both groups exhibited increased preoperative opioid consumption compared to patients who never smoked (88.89% vs 42.04%; P < .001 for current users; 59.42% vs 42.04% for former users; P = .008). There was also a dose-depended relationship between smoking and increased preoperative opioid consumption. No differences in average length of stay or direct postoperative complications were observed between patients with a history of tobacco use and nonusers and between patients taking opioid medication preoperatively and those who were opioid-naïve in this cohort. CONCLUSION Geriatric female spine patients with a history of smoking have a higher incidence of preoperative opioid consumption. Opioid intake appears to increase with the number of pack-years in patients with a history of smoking or who currently smoke. These findings highlight the importance of smoking cessation in older spine candidates, especially women, as it may encourage a decrease in opioid consumption even outside of the operative setting.
INTRODUCTION Depressive disorder has been shown to be an independent risk factor for opioid abuse and increased perception of postoperative pain. However, the relationship between AD and preoperative ...quality of life, narcotic intake, and pain, has not been previously explored in spine surgery candidates. METHODS The records of 117 consecutive adult patients who underwent elective spinal surgery between October 2016 and August 2017 at a single institution were reviewed. Inclusion criteria also included patients who underwent a preoperative pain assessment within 30 days prior to their planned surgery using the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29). Primary outcomes included preoperative ratings of anxiety, depression, pain, preoperative narcotic use, and postoperative hospital length of stay, intra- and post-operative complications in patients with AD (depression, anxiety, bipolar disorder, and/or PTSD) compared to controls. RESULTS The average rating of Pain Intensity was notably higher in the AD group compared controls (P = .004). The AD group had more patients complaining of high pain levels (>6) compared to the controls (P = .026). Controls with high-pain had a greater incidence of preoperative narcotic use compared to the low-pain cohort (P = .029). However, there was no difference in the actual dose of daily narcotic medication taken in MEDD between the AD and control groups, or between the low- and high-pain score groups in the control and AD groups respectively. Surgical procedure types, hospital length of stays, and perioperative complications were comparable in the AD and control groups. Patients who underwent lumbar short surgeries reported high levels of preoperative pain intensity, while patients who underwent anterior cervical procedures on average reported lower levels in both groups. CONCLUSION ADs may impact the degree of preoperative pain interference and the intake of narcotic medication independently from pain intensity ratings. These findings highlight the importance of detecting and treating depression and anxiety in patients suffering from spine disorders, regardless of surgical intervention planning.
To compare perioperative outcomes of obese versus non-obese adult patients who underwent degenerative scoliosis spine surgery.
235 patients who underwent thoracolumbar adult spinal deformity (ASD) ...surgery (≥4 levels) were identified and categorized into two cohorts based on their body mass indices (BMI): obese (BMI ≥30 kg/m2; n = 81) and non-obese (BMI <30 kg/m2; n = 154). Preoperative (demographics, co-morbidities, American Society of Anesthesiologists (ASA) score and modified frailty indices (mFI-5 and mFI-11)), intraoperative (estimated blood loss (EBL) and anesthesia duration), and postoperative (complication rates, Oswestry Disability Index (ODI) scores, discharge destination, readmission rates, and survival) characteristics were analyzed by student’s t, chi-squared, and Mann-Whitney U tests.
Obese patients were more likely to be Black/African-American (p < 0.05, OR:4.11, 95% CI:1.20–14.10), diabetic (p < 0.05, OR:10.18, 95% CI:4.38–23.68) and had higher ASA (p < .01) and psoas muscle indices (p < 0.0001). Furthermore, they had greater pre- and post-operative ODI scores (p < 0.05) with elevated mFI-5 (p < 0.0001) and mFI-11 (p < 0.01). Intraoperatively, obese patients were under anesthesia for longer time periods (p < 0.05) with higher EBL (p < 0.05). Postoperatively, while they were more likely to have complications (OR:1.77, 95% CI:1.01 – 3.08), had increased postop days to initiate walking (p < .05) and were less likely to be discharged home (OR:0.55, 95% CI:0.31–0.99), no differences were found in change in ODI scores or readmission rates between the two cohorts.
Obesity increases pre-operative risk factors including ASA, frailty and co-morbidities leading to longer operations, increased EBL, higher complications and decreased discharge to home. Pre-operative assessment and systematic measures should be taken to improve peri-operative outcomes.
•Compared 154 obese versus 81 non-obese adult degenerative scoliosis patients.•Obese patients had higher ASA, modified frailty, pre- and post-operative ODI scores.•Obese patients had more complications and were less likely to be discharged to home.•No differences in change in ODI scores or readmission rates between the two cohorts.•BMI alone does not capture peri-operative risks present in obese patients.
Vaccination against hepatitis B virus (HBV) is effective at preventing vertical transmission. Sierra Leone, Liberia, and Guinea are hyperendemic West African countries; yet, childhood vaccination ...coverage is suboptimal, and the determinants of incomplete vaccination are poorly understood. We analyzed national survey data (2018–2020) of children aged 4–35 months to assess complete HBV vaccination (receiving 3 doses of the pentavalent vaccine) and incomplete vaccination (receiving <3 doses). Statistical analysis was conducted using the complex sample command in SPSS (version 28). Multivariate logistic regression was used to identify determinants of incomplete immunization. Overall, 11,181 mothers were analyzed (4,846 from Sierra Leone, 2,788 from Liberia, and 3,547 from Guinea). Sierra Leone had the highest HBV childhood vaccination coverage (70.3%), followed by Liberia (64.6%) and Guinea (39.3%). Within countries, HBV vaccination coverage varied by socioeconomic characteristics and healthcare access. In multivariate regression analysis, factors that were significantly associated with incomplete vaccination in at least one country included sex of the child, Muslim mothers, lower household wealth index, <4 antenatal visits, home delivery, and distance to health facility vaccination (all p < 0.05). Understanding and addressing modifiable determinants of incomplete vaccination will be essential to help achieve the 2030 viral hepatitis elimination goals.
Study Design
Cross-Sectional Study
Objectives
Socioeconomic status (SES) is a fundamental root of health disparities, however, its effect on surgical outcomes is often difficult to capture in ...clinical research, especially in spine surgery. Here, we present a large single-center study assessing whether SES is associated with cause-specific surgical outcomes.
Methods
Patients undergoing spine surgery between 2015 and 2019 were assigned income in accordance with the national distribution and divided into quartiles based on the ZIP code-level median household income. We performed univariate, chi-square, and Analysis of Variance (ANOVA) analysis assessing the independent association of SES, quantified by household income, to operative outcomes, and multiple metrics of opioid consumption.
Results
1199 patients were enrolled, and 1138 patients were included in the analysis. Low household income was associated with the greatest rates of 3-month opioid script renewal (OR:1.65, 95% CI:1.14-2.40). In addition, low-income was associated with higher rates of perioperative opioid consumption compared to higher income including increased mean total morphine milligram equivalent (MME) 252.25 (SD 901.32) vs 131.57 (SD 197.46) (P < .046), and inpatient IV patient-controlled analgesia (PCA) MME 121.11 (SD 142.14) vs 87.60 (SD 86.33) (P < .023). In addition, household income was independently associated with length of stay (LOS), and emergency room (ER) revisits with low-income patients demonstrating significantly longer postop LOS and increasing postoperative ER visits.
Conclusions
Considering the comparable surgical management provided by the single institution, the associated differences in postoperative outcomes as defined by increased morbidities and opioid consumption can potentially be attributed to health disparities caused by SES.
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