The Cost of Providing District-Level Surgery in Malawi.

BACKGROUND: Three district hospitals in Malawi that provide essential surgery, which for many patients can be lifesaving or prevent disability, formed the setting of this costing study. METHODS: All resources used at district hospitals for the delivery of surgery were identified and quantified. The hospital departments were divided into three categories of cost centres-the final cost centre, intermediate and ancillary cost centres. All costs of human resources, buildings, equipment, medical and non-medical supplies and utilities were quantified and allocated to surgery through step-down accounting. RESULTS: The total cost of surgery, including post-operative care, ranged from US$ 329,000 per year to more than twice that amount at one of the hospitals. At two hospitals, it represented 16-17% of the total cost of running the hospital. The main cost drivers of surgery were transport and inpatient services, including catering. The cost of a C-section ranged from $ 164 to 638 that of a hernia repair from $ 137 to 598. Evacuations from uterus were cheapest mainly because of the shorter duration of patient stay. CONCLUSION: Low bed occupancy rates and utilisation rates of the operating theatres suggest overcapacity but may also indicate a potential to scale up surgery. This may be achieved by adding surgical staff, although there may be rate-limiting steps, such as demand for surgery in the community or capacity to provide anaesthesia. If a scale-up of surgery cannot be realised, hospital managers may be forced to reduce the number of beds, reorganise wards and/or reallocate staff to achieve better economies of scale.

Quality of Surgery in Malawi: Comparison of Patient-Reported Outcomes After Hernia Surgery Between District and Central Hospitals.

BACKGROUND: District hospitals in Africa could meet the essential surgical needs of rural populations. However, evidence on outcomes is needed to justify investment in this option, given that surgery at district hospitals in some African countries is usually undertaken by non-physician clinicians. METHODS: Baseline and 2-3-month follow-up measurements were undertaken on 98 patients who had undergone hernia repairs at four district and two central hospitals in Malawi, using a modified quality-of-life tool. RESULTS: There was no significant difference in outcomes between district and central hospital cases, where a good outcome was defined as no more than one severe and three mild symptoms. Outcomes were marginally inferior at district hospitals (OR 0.79, 95% CI 0.63-1.0). However, in the 46 cases that underwent elective surgery at district hospitals, baseline scores for severe symptoms were worse (mean = 3.5) than in the 23 elective central hospital cases (mean = 2.5), p = 0.004. Also, the mean change (improvement) in symptom score was higher in district versus central hospital cases (3.9 vs. 2.3). CONCLUSION: The study results support the case for investing in district hospital surgery in sub-Saharan Africa to increase access to essential surgical care for rural populations. This could free up specialists to undertake more complex and referred cases and reduce emergency presentations. It will require investments in training and resources for district hospitals and in supervision from higher levels.

Surgical Capacity at District Hospitals in Zambia: From 2012 to 2016.

BACKGROUND: Sub-Saharan Africa has one of the highest burdens of surgically treatable conditions in the world and the highest unmet need, especially in rural areas. Zambia is one of the countries in the region taking steps to improve surgical care for its rural populations. AIM: To demonstrate changes in surgical capacity in Zambia's district hospitals over a 3-year period and to provide a baseline from which future interventions in surgical care can be assessed. METHODS: A cross-sectional assessment of surgical capacity, using a modified WHO questionnaire, was administered in first-level hospitals in nine of Zambia's ten provinces between November 2012 and February 2013 and again between February and April 2016. The two assessments allowed measurement of changes in surgical workforce, infrastructure, equipment, drugs and consumables; and numbers of major surgical procedures performed over two 12-month periods prior to the assessments. RESULTS: There was a significant increase, 2013-2016, in number of theatre staff, from 174 (mean 4.4; SD 1.7) to 235 (mean 6; SD 2.9), P = 0.02. However, the percentage of hospitals with functioning anaesthetic machines dropped from 64 to 41%. There was also a drop in hospitals reporting availability of instruments, drugs and consumables from 38 to 24 (97-62%) and from 28 to 24 (72-62%), respectively. The median number of caesarean sections in 2012 was 99 [interquartile range (IQR) 42-187] and 100 (IQR 42-126) in 2015 (P value =0.53). The median number of major surgical procedures in 2012 was 54 (IQR 10-113) and 66 (IQR 18-168) in 2015 (P = 0.45). CONCLUSION: An increase in the first-level hospital surgical workforce between 2013 and 2016 was accompanied by reductions in essential equipment and consumables for surgery, and no changes in surgical output. Periodic monitoring of resource availability is needed to address shortages and make safe surgery available to rural populations.

Who accesses surgery at district level in sub-Saharan Africa? Evidence from Malawi and Zambia.

OBJECTIVES: To examine age and gender distribution for the most common types of surgery in Malawi and Zambia. METHODS: Data were collected from major operating theatres in eight district hospitals in Malawi and nine in Zambia. Raw data on surgical procedures were coded by specialist surgeons for frequency analyses. RESULTS: In Malawi female surgical patients had a mean age of 25 years, with 91% aged 16-40 years. Females accounted for 85%, and obstetric cases for 75%, of all surgical patients. In Zambia, female surgical patients had a mean age of 26, with 75% aged 16-40 years. They accounted for 55% of all cases, 34% being obstetric. Male surgical patients in Malawi were on average older (33 years) than in Zambia (23 years). General surgical cases in men and women, respectively, had a median age of 42 and 32 in Malawi and 26 and 30 in Zambia. The median age of trauma patients was 12 in males and 10 in females in both countries. Children aged 0-15 years accounted for 64-65% of all trauma cases in Malawi and 57-58% in Zambia, with peak incidences in 6- to 10-year-olds. CONCLUSIONS: Women of reproductive (16-45 years) mainly undergoing Caesarean sections and children aged 0-15 years who accounted for two-thirds of trauma cases are the main patient populations undergoing surgery at district hospitals in Zambia and Malawi. Verification and analysis of routine hospital data, across 10-30% of districts countrywide, demonstrated the need to prioritise quality assurance in surgery and anaesthesia, and preventive interventions in children.

Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia.

BACKGROUND: Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. METHODS: This qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues-medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders. RESULTS: In Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills. CONCLUSIONS: The paper provides new evidence concerning the benefits of 'task shifting' and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.

Effects of a Lactobacillus salivarius probiotic intervention on infection, cold symptom duration and severity, and mucosal immunity in endurance athletes.

The purpose of this study was to examine the effects of a probiotic supplement during 4 mo of spring training in men and women engaged in endurance-based physical activities on incidence of upper respiratory tract infections (URTI) and mucosal immune markers. Sixty-six highly active individuals were randomized to probiotic (n = 33) or placebo (n = 33) groups and, under double-blind procedures, received probiotic (PRO: Lactobacillus salivarius, 2 × 1010 bacterium colony-forming units) or placebo (PLA) daily for 16 wk. Resting blood and saliva samples were collected at baseline and after 8 and 16 wk. Weekly training and illness logs were kept. Fifty-four subjects completed the study (n = 27 PRO, n = 27 PLA). The proportion of subjects on PRO who experienced 1 or more wk with URTI symptoms was not different from that of those on PLA (PRO .58, PLA .59; p = .947). The number of URTI episodes was similar in the 2 groups (PRO 1.6 ± 0.3, PLA 1.4 ± 0.3; p = .710). Severity and duration of symptoms were not significantly different between treatments. Blood leukocyte, neutrophil, monocyte, and lymphocyte counts; saliva IgA; and lysozyme concentrations did not change over the course of the study and were not different on PRO compared with PLA. Regular ingestion of L. salivarius does not appear to be beneficial in reducing the frequency of URTI in an athletic cohort and does not affect blood leukocyte counts or levels of salivary antimicrobial proteins during a spring period of training and competition.

Sex differences in immune variables and respiratory infection incidence in an athletic population.

The purpose of this study was to examine sex differences in immune variables and upper respiratory tract infection (URTI) incidence in 18-35 year-old athletes engaged in endurance-based physical activity during the winter months. Eighty physically active individuals (46 males, 34 females) provided resting venous blood samples for determination of differential leukocyte counts, lymphocyte subsets and whole blood culture multi-antigen stimulated cytokine production. Timed collections of unstimulated saliva were also made for determination of saliva flow rate, immunoglobulin A (IgA) concentration and IgA secretion rate. Weekly training and illness logs were kept for the following 4 months. Training loads averaged 10 h/week of moderate-vigorous physical activity and were not different for males and females. Saliva flow rates, IgA concentration and IgA secretion rates were significantly higher in males than females (all P < 0.01). Plasma IgA, IgG and IgM concentrations and total blood leukocyte, neutrophil, monocyte and lymphocyte counts were not different between the sexes but males had higher numbers of B cells (P < 0.05) and NK cells (P < 0.001). The production of interleukins 1 beta, 2, 4, 6, 8 and 10, interferon-gamma and tumour necrosis factor-alpha in response to multi-antigen challenge were not significantly different in males and females (all P > 0.05). The average number of weeks with URTI symptoms was 1.7 +/- 2.1 (mean +/- SD) in males and 2.3 +/- 2.5 in females (P = 0.311). It is concluded that most aspects of immunity are similar in men and women in an athletic population and that the observed differences in a few immune variables are not sufficient to substantially affect URTI incidence. Sex differences in immune function among athletes probably do not need to be considered in future mixed gender studies on exercise, infection and immune function unless the focus is on mucosal immunity or NK cells.

ACE I/D and ACTN3 R/X polymorphisms and muscle function and muscularity of older Caucasian men.

The progressive decline in strength and power with ageing leads to compromised mobility and an increased risk of falls. Angiotensin converting enzyme (ACE) I/D and alpha actinin 3 (ACTN3) R/X polymorphisms have been suggested to influence variations in skeletal muscle function and body composition. This study investigated the associations between these polymorphisms and knee extensor muscle function and muscularity in older Caucasian men. Strength was measured isometrically and isokinetically (at 30 and 240 degrees s(-1)), and the time course of the evoked twitch response recorded. A dual-energy X-ray absorptiometry scan measured thigh and whole body non-skeletal lean mass. ACE I/D and ACTN3 R/X polymorphisms were determined by polymerase chain reaction, and serum ACE activity using spectrophotometry. Whole body and thigh non-skeletal lean mass were independent of ACE and ACTN3 genotypes. Absolute and relative high velocity strength, and the time course of an evoked twitch were not associated with ACE or ACTN3 genotype. Serum ACE activity was negatively correlated with relative high velocity torque (R = -0.23, P = 0.03), and exhibited a positive trend with knee extensor isometric strength (R = 0.19, P = 0.07). ACE I/D and ACTN3 R/X polymorphisms were not associated with muscle function or muscularity phenotypes in older Caucasian men, although serum ACE activity appeared to have a small effect on muscle function.

Human angiotensin-converting enzyme I/D and alpha-actinin 3 R577X genotypes and muscle functional and contractile properties.

The angiotensin-converting enzyme (ACE) I/D and alpha-actinin 3 (ACTN3) R/X polymorphisms have been suggested to influence variations in skeletal muscle function. This study investigated the association between ACE I/D and ACTN3 R/X polymorphisms and muscle strength and contractile properties in young UK Caucasian men. Measurements of the knee extensor muscles were taken from 79 recreationally active but non-strength-trained males on two occasions. Isometric knee extensor strength was measured using a conventional strength-testing chair. Maximal twitches were electrically evoked by percutaneous stimulation to assess time-to-peak tension, half-relaxation time and peak rate of force development. The torque-velocity relationship was measured at four angular velocities (0, 30, 90 and 240 deg s(-1)) using isokinetic dynamometry, and the relative torque at high velocity was calculated (torque at 240 deg s(-1) as a percentage of that at 30 deg s(-1)). The ACE I/D and ACTN3 R/X polymorphisms were genotyped from whole blood by polymerase chain reaction. Serum ACE activity was assayed from serum using automated spectrophotometry. Physical characteristics were independent of either genotype. Absolute and relative high-velocity torque were not influenced by ACE or ACTN3 genotypes. Isometric strength and the time course of a maximal twitch were independent of ACE and ACTN3 genotypes. Serum ACE activity was significantly dependent on ACE genotype (P < 0.001), but was not associated with any measure of functional or contractile properties. Knee extensor functional and contractile properties, including high-velocity strength, were not influenced by ACE and ACTN3 polymorphisms in a cohort of UK Caucasian males. Any influence of these individual polymorphisms on human skeletal muscle does not appear to be of sufficient magnitude to influence function in free-living UK Caucasian men.

Tendinopathies in the upper extremity: a paradigm shift.

Epicondylitis and de Quervain's tenosynovitis are two common diagnoses seen by hand therapists in clinical practice. Traditionally, these conditions have been viewed as being due to an inflammatory process and treated as such. New research shows that tendons exhibit areas of degeneration and a distinct lack of inflammatory cells. Tendinosis is degeneration of the collagen tissue due to aging, microtrauma, or vascular compromise. This article reviews key literature related to tendinopathies in the lower extremity and comments on the dearth of similar articles for the elbow and forearm. Hand therapists are encouraged to embrace this new terminology and to engage in research in this difficult area to improve treatment regimens and outcome measures.