Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments.

BACKGROUND: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. METHODS: We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. RESULTS: Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. CONCLUSIONS: Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Follow up colonoscopy may be omissible in uncomplicated left-sided acute diverticulitis diagnosed with CT- a retrospective cohort study.

International guidelines recommend colonoscopy following hospitalisation for acute diverticulitis. There is a paucity of evidence supporting the efficacy of colonoscopy in this context, particularly for patients with CT-diagnosed uncomplicated left-sided diverticulitis. This study aims to investigate the frequency that colorectal cancer (CRC) and advanced adenomas (AA) are identified during follow-up colonoscopy after hospitalisation with CT-proven left-sided diverticulitis for the first time in a UK population. In this single-centre retrospective-cohort study all patients presenting with CT-diagnosed uncomplicated left-sided diverticulitis between 2014 and 2017 were identified. The incidence of histologically confirmed CRC and AA identified at follow-up colonoscopy 4-6 weeks following discharge was assessed. 204 patients with CT proven uncomplicated left-sided diverticulitis underwent follow-up colonoscopy. 72% were female and the median age was 63 years. There were no major complications. 22% of patients were found to have incidental hyperplastic polyps or adenomas with low-grade dysplasia. No CRC or AA were found. Routine colonoscopy following acute diverticulitis in this cohort did not identify a single CRC or AA and could arguably have been omitted. This would significantly reduce cost and pressure on endoscopy departments, in addition to the pain and discomfort that is commonly associated with colonoscopy.

Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis.

BACKGROUND: Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment. METHODS: The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis. DISCUSSION: The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018112990.

Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic sympathectomy - A quality of life and cost effectiveness analysis.

AIM: To estimate cost-effectiveness of botulinum toxin therapy for axillary hyperhidrosis compared to the standard surgical intervention of endoscopic thoracic sympathectomy (ETS). METHODS: The validated dermatology life quality index questionnaire was given to patients attending for treatment over a 4 month period, to assess their quality of life (QoL) over the preceding week (n = 44). Follow-up was performed 4-6 weeks later by telephone using the same questionnaire to validate the effectiveness of the treatment. The duration of effect of the botulinum toxin treatment was also recorded and this data was used as the basis for cost effectiveness analysis. Using HIPE data, the baseline cost for single intervention using botulinum toxin and ETS was retrieved. Using figures provided by HIPE and expert opinion of the costs of complications, a stochastic model for 10,000 patients was used to evaluate the total costs for ETS including the complications. RESULTS: The results from the QoL analysis show that botulinum toxin therapy is a successful therapy for improvement of symptoms. It was revealed that the mean interval before recurrence of original symptoms after botulinum toxin therapy was 5.6 months. The baseline cost for both treatments are €389 for botulinum toxin and €9389 for uncomplicated ETS. The stochastic model yields a mean cost of €11,390 for ETS including complications. CONCLUSIONS: Treatments reached cost equivalence after 13.3 years. However, given the efficacy of the botulinum toxin therapy and the low risk we propose that botulinum toxin therapy for hyperhidrosis should be considered the gold standard.

A prospective analysis of thyroidectomy outcomes in a resource-limited setting.

BACKGROUND: This study aimed to document thyroidectomy outcomes in the surgical endocrine unit, Mulago Hospital, Kampala, Uganda. The burden of global surgical disease is currently receiving much attention, especially in countries experiencing epidemiological transition. There is a paucity of publications on surgical outcomes from Sub-Saharan Africa. International thyroid guidelines from high-income countries do not factor in the logistical challenges or the advanced pathology faced by the surgeon in resource-limited settings. METHODS: This was a prospective cohort study in 2013. Eight peri-operative variables of poor outcome were analysed statistically against six outcomes variables. Data was collected from 0 to 6 months post-operatively. RESULTS: Forty-two thyroidectomies were performed over a 3-month period (female = 38). Intraoperative events recorded included rebleeding = 10 %, infection = 0 %, transient voice symptoms = 30 %, transient hypocalcaemia = 12.5 %, recurrent laryngeal nerve (RLN) paralysis = 7.5 % and permanent hypocalcaemia = 15 %. There was a weak powered association between RLN paralysis and total thyroidectomy and smaller thyroid size. There were associations between large thyroid size and both permanent hypocalcaemia and rebleeding. Younger patients showed statistically more transient voice changes compared to older patients. Older patients were statistically more likely to develop rebleeding. Shorter operative duration was associated with transient voice change, permanent hypocalcaemia and rebleeding. Airway difficulties and transient hypocalcaemia were statistically significant in prolonged procedures. CONCLUSIONS: Whilst the thyroidectomy outcomes are not equal to international standards, an acceptable standard is achievable in this resource-limited setting. Poor outcomes are multifactorial but extremes of thyroid size, extremes of operation duration and total thyroidectomies all have statistically poorer outcomes in this setting.