The impact of COVID-19 pandemic on the mortality and morbidity of patients undergoing trauma surgery: a report from the UK Corona TRAUMA Surge (UKCoTS) study.

PURPOSE: To assess the impact of the COVID-19 pandemic on the outcomes of the patients who underwent trauma surgery during the peak of the pandemic. METHODS: The UKCoTS collected the postoperative outcomes of consecutive patients who underwent trauma surgery across 50 centres during the peak of the pandemic (April 2020) and during April 2019. RESULTS: Patients who were operated on during 2020 were less likely to be followed up within a 30-day postoperative period (57.5% versus 75.6% p <0.001). The 30-day mortality rate was significantly higher during 2020 (7.4% versus 3.7%, p <0.001). Likewise, the 60-day mortality rate was significantly higher in 2020 than in 2019 (p <0.001). Patients who were operated on during 2020 had lower rates of 30-day postoperative complications (20.7% versus 26.4%, p <0.001). CONCLUSIONS: Postoperative mortality was higher during the first wave of the COVID-19 pandemic compared to the same period in 2019, but with lower rates of postoperative complications and reoperation.

Optimizing Surgical Care Amidst COVID-19: A Scoping Review of Practices and Policies.

BACKGROUND: The coronavirus disease (COVID-19) pandemic significantly disrupted surgical care worldwide, affecting different specialties in various ways. Lockdowns, surges in COVID-19 cases, and changes in hospital policies notably impacted patient attendance, management practices, and access to surgical services. This scoping review examines the adverse impacts of the COVID-19 pandemic on surgical services and the policies adopted to address these care barriers. METHODS: We conducted a comprehensive literature review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Our search, spanning 31 December 2019, to 29 January 2023, focused on understanding the multifaceted impacts of COVID-19 on surgical services, particularly across different specialties. RESULTS: An analysis of 75 articles indicated that the pandemic challenged surgeons worldwide to maintain a balance between delivering emergency and elective surgical care, and implementing safety measures against viral transmission. There was a marked decline in the surgical volume, leading to extended waitlists and decreased operating theater usage. Strategies such as prioritizing medically necessary and time-sensitive surgeries and integrating telemedicine have emerged as pivotal for ensuring the continuity of urgent care. Despite the reduced rates, essential surgeries such as appendectomies and cancer-related operations continued, yet faced hurdles, including reduced staffing, limited operating theater capacity, and complications in patient transfers. CONCLUSIONS: This review emphasizes the steep reduction in surgical service utilization at the beginning of the pandemic and emergence of new compounded barriers. Policies that designated surgeries as essential, and focused on equitable and timely access, were effective. Incorporating these findings into post-pandemic assessments and future planning is crucial to sustain adequate surgical care during similar health emergencies.

Burden of Cancer and Utilization of Local Surgical Treatment Services in Rural Hospitals of Ethiopia: A Retrospective Assessment from 2014 to 2019.

BACKGROUND: Global cancer estimations for Ethiopia announced 77 352 new cases in 2020 based on the only population-based registry in Addis Ababa. This study characterizes cancer patients in rural Ethiopia at 8 primary and secondary hospitals between 2014 and 2019. PATIENTS AND METHODS: All clinically or pathologically confirmed cancer cases that were diagnosed between 1 May 2014 and 29 April 2019 were included. A structured data extraction tool was used to retrospectively review patients' charts and descriptive analysis was done. RESULTS: A total of 1298 cancer cases were identified, of which three-fourths were females with a median age of 42 years. Breast (38%) and cervical (29%) cancers were the most common among females, while prostate (19%) and oesophageal cancers (16%) were the most common among males. Only 39% of tumors were pathologically confirmed. Nearly two-thirds of the cases were diagnosed at an advanced stage. Surgery was the only accessible treatment option for more than half of the cancer patients, and systemic treatment (except endocrine) was rarely available. One in 5 patients did not receive the recommended surgical procedure, half due to patient refusal or lack of the patient returning to the hospital. CONCLUSION: The pattern of cancer diagnoses in rural hospitals shows an exceptionally high burden in women in their middle-ages due to breast and cervical cancers. Advanced stage presentation, lack of pathology services, and unavailability of most systemic treatment options were common. The surgery was offered to nearly 60% of the patients, showing the significant efforts of health workers to reduce sufferings.

COVID-19 Response Unites Perioperative Teams at a Recently Merged Health Care System.

Advocate Aurora Health, located in the north-central United States, is the result of a merger between two large health care organizations in April 2018. The health care system comprises 26 hospitals, offers more than 500 sites of care, and employs 75,000 team members. This article discusses the effects that coronavirus disease 2019 had on the perioperative services departments while directors and site leaders were still managing the complexities of the merger. Included are strategies used to address the challenges created by the pandemic, special considerations based on level-of-care capacity, the effect that the hold on elective surgeries had on staffing assignments, the reactivation process when elective surgery resumed, and the importance of keeping the perioperative team members informed and safe. It also illustrates how facing the challenges caused by the pandemic helped to solidify the merger of the two health care organizations.

Non- COVID fatalities in the COVID era: A paradigm shift in the face of a pandemic- lessons learnt (or not).

INTRODUCTION: The rapid spread of the coronavirus pandemic and the associated high morbidity and mortality led to sudden lock down, forcing the elderly and others in the high risk group into isolation. Elective health care services including diagnostics, therapeutics and elective surgical services were put on hold, leading to delays seriously affecting cancer and non-cancer related services. In spite of lessons learnt during the first wave, similar issues have persisted during the second wave, increasing the pressure on an already fragile infrastructure. METHODS: Information related to surgical patients admitted since lock down (March to August 2020) as an emergency was collected on a structured proforma and analysed. Data was gathered from prospectively kept patient admission lists and Electronic Discharge summaries. All the patients who were directly or indirectly affected with poor outcomes including delayed diagnosis and treatment were identified and included in the analysis. RESULTS: A total of 185 patients were admitted as an emergency during this period. Of these Eight patients admitted under surgical care were included in the study. Four out of eight patients were diagnosed with advanced cancer and the remainder presented with complications of benign pathologies. Of the four patients with advanced cancer, three patients had advanced colorectal and the fourth had advanced ovarian cancer. All four patients either presented late or had delayed access to investigations. Three out four patients with benign disease presented with complications due to cancellation of elective and semi urgent services. One patient who was COVID positive and presented with bowel perforation died after a prolonged hospital stay. CONCLUSION: There is definite evidence of unfavourable patient outcomes in non COVID patients as a result of the COVID pandemic. As COVID is unlikely to whither down in the very near future and highs and lows are expected, rapid and safe reintroduction of elective health care services affected by COVID is the call of the hour. In addition, more efforts should be directed towards increasing awareness amongst patients regarding the importance of reporting red flag symptoms and encouraging them to access health care services.

Prioritizing Surgical Services during on-Going Pandemic Response: Modification and Reliability of the Medically Necessary Time Sensitive Surgery (MeNTS) Scoring Tool.

Health systems are struggling to manage a fluctuating volume of critically ill patients with COVID-19 while continuing to provide basic surgical services and expand capacity to address operative cases delayed by the pandemic. As we move forward through the next phases of the pandemic, we will need a decision-making system that allows us to remain nimble as clinicians to meet our patient's needs while also working with a new framework of healthcare operations. Here, we present our quality improvement process for the adaptation and application of the Medically Necessary Time-Sensitive (MeNTS) toolto gynecologic surgical services beyond the initial COVID response and into recovery of surgical services; with analysis of the reliability of the modified-MeNTS tool in our multi-site safety net hospital network. This multicenter study evaluated the gynecology surgical case volume at three tertiary acute care safety net institutions within the LA County Department of Health Services: Harbor-UCLA (HUMC), Olive View Medical Center (OVMC), and Los Angeles County + University of Southern California (LAC+USC). We describe our modified-Delphi approach to adapt the MeNTS tool in a structured fashion and its application to gynecologic surgical services. Blinded reviewers engaged in a three-round iterative adaptation and final scoring utilizing the modified tool. The cohort consisted of 392 female consecutive gynecology patients across three Los Angeles County Hospitals awaiting scheduled procedures in the surgical queue.The majority of patients were Latina (74.7%) and premenopausal (67.1%). Over half (52.4%) of the patients had cardiovascular disease, while 13.0% had lung disease, and 13.8% had diabetes. The most common indications for surgery were abnormal uterine bleeding (33.2%), pelvic organ prolapse (19.6%) and presence of an adnexal mass (14.3%). Minimally invasive approaches via laparoscopy, robotic-assisted laparoscopy, or vaginal surgery was the predominant planned surgical route (54.8%). Modified-MeNTS scores assumed a normal distribution across all patients within our cohort (Median 33, Range 18-52). Overall, ICC across all three institutions demonstrated "good" interrater reliability (0.72). ICC within institutions at HUMC and OVMC were categorized as "good" interrater reliability, while LAC-USC interrater reliability was categorized as "excellent" (HUMC 0.73, OVMC 0.65, LAC+USC 0.77). The modified-MeNTS tool performed well across a range of patients and procedures with a normal distribution of scores and high reliability between raters. We propose that the modified-MeNTS framework be considered as it employs quantitative methods for decision-making rather than subjective assessments.

Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic.

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital.

The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.

Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services.

There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.

Missed opportunities for epilepsy surgery referrals in Bhutan: A cohort study.

OBJECTIVE: To quantify the missed opportunities for epilepsy surgery referral and operationalize the Canadian Appropriateness of Epilepsy Surgery (CASES) tool for use in a lower income country without neurologists. METHODS: People with epilepsy were recruited from the Jigme Dorji Wangchuck National Referral Hospital from 2014-2016. Each participant was clinically evaluated, underwent at least one standard EEG, and was invited to undergo a free 1.5 T brain MRI. Clinical variables required for CASES were operationalized for use in lower-income populations and entered into the free, anonymous website tool. FINDINGS: There were 209 eligible participants (mean age 28.4 years, 56 % female, 179 with brain MRI data). Of the 179 participants with brain MRI, 43 (24.0 %) were appropriate for an epilepsy surgery referral, 21 (11.7 %) were uncertain, and 115 (64.3 %) were inappropriate for referral. Among the 43 appropriate referral cases, 36 (83.7 %) were "very high" and 7 (16.3 %) were "high" priorities for referral. For every unit increase in surgical appropriateness, quality of life (QoL) dropped by 2.3 points (p-value <0.001). Among the 68 patients who took >1 antiepileptic drug prior to enrollment, 42 (61.8 %) were appropriate referrals, 14 (20.6 %) were uncertain, and 12 (17.6 %) were inappropriate. CONCLUSION: Approximately a quarter of Bhutanese epilepsy patients who completed evaluation in this national referral-based hospital should have been evaluated for epilepsy surgery, sometimes urgently. Surgical services for epilepsy are an emerging priority for improving global epilepsy care and should be scaled up through international partnerships and clinician support algorithms like CASES to avoid missed opportunities.

Limited Intragenerational Mobility of Surgical Caseload of Iowa Hospitals.

We previously calculated the Gini index for 121 Iowa hospitals over the ten-year period 2007-2016. The Gini index is a statistic used in economics to assess difference in the distribution of wealth among groups. We reported a high degree of "inequality" among hospitals. In this paper, we extend this work by calculating the intragenerational mobility for the hospitals present in 2007-2008 and 2015-2016. Whereas in economics intragenerational mobility often is measured as changes in income over time within a group, we study changes in hospitals' surgical caseloads. Intragenerational mobility was quantified using the Spearman rank correlation, the slope of the ordinary least squares (OLS) regression line in the log scale, and the Shorrocks trace index. The results were consistent across the three measures. There was a low degree of mobility for the surgical caseloads of the hospitals during the 10-year period under study. For example, based on the slope of the OLS regression, intragenerational mobility was not significantly different from zero (P > 0.05). None (0%) of the 113 hospitals with at least 10 cases both periods increased from the 1st to 5th quintile, 1st to 4th quintile, 2nd to 5th quintile, 2nd to 4th quintile, or even from 3rd to 5th quintile. The results show the importance of hospitals not investing irrationally based on false hope of surgical growth.

What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa?

BACKGROUND: Children constitute 50% of Africa's population. Sub-Saharan Africa has the highest under-five mortality rates in the world. This study is the first to document the availability of paediatric ENT and paediatric surgery services in Africa. OBJECTIVE: To determine the availability of paediatric ENT services in Africa, as well as that of paediatric surgery that would complement paediatric ENT. METHOD: A descriptive observational study in the form of an online questionnaire was distributed by email to known ENT and paediatric surgeons based in Africa. RESULTS: Surgeons from twelve of 23 African countries responded to the survey. Seven countries had both ENT and paediatric surgery responses. In 8 of the 11 countries, the number of ENT surgeons per country was<6% of that of the UK, with 1 ENT surgeon per 414,000 people and 1 paediatric surgeon per 1,181,151 people. Ten of 11 countries reported hearing assessments in schools were poor/unavailable. Seventy-three percent responded positively for access to rigid laryngoscopes, bronchoscopes, cameras and fibre optic cables, tracheostomy, anaesthesia and nurse practitioners. Access was reported as poor/unavailable for balloon dilators 73% (8/11 countries); CPAP machines 73% (8/11) and sleep studies 82% (9/11 countries). Flexible endoscopes were available in 50% (4/8 countries), 75% (6/8 countries) had access to a camera, monitor and stack. Thirty-eight percent (3/9 countries) reported no ENT specialists with paediatric training. CONCLUSIONS: There is a great shortage of paediatric ENT and paediatric surgery services in Africa. More regional training opportunities and health infrastructure for these surgical specialties are needed. Collaborative development of paediatric ENT, surgery and anaesthesia should be considered to improve ENT-related child health in Africa.

Facilitating factors in overcoming barriers to cataract surgical services among the bilaterally cataract blind in Southern India: A cross-sectional study.

Purpose: To effectively address cataract blindness, increasing sight-restoring surgeries among the bilaterally blind are essential. To improve uptake of surgical services among this group, evidence regarding the problems of access is vital. Barriers in accessing eye care services have previously been reported but not specific to bilaterally cataract blind patients. Further, there is a gap in knowledge regarding factors facilitating access to eye care. Our aims were to (1) report proportion of bilaterally cataract blind patients undergoing surgery and sight restoration rate (SRR) and (2) analyze barriers and factors enabling access to eye care services among bilaterally cataract blind patients. Methods: Retrospective analysis of interview and clinical data of bilaterally cataract blind patients undergoing surgery through outreach services at the base hospital, from June 2015 to May 2016, was performed. Demographic data, vision, postoperative visual outcomes, barriers, and facilitating factors in accessing cataract surgical services were obtained. Results: Bilateral cataract blindness was present in 196/3178 (6.2%, 95% confidence interval 5.4-7.06) patients. SRR was 6.5%. Fear of surgery (24.2%) and lack of family support/escort (22.9%) were the most common barriers. Neighbors and acquaintances (28.6%), general health workers (20.2%), and persons who had undergone cataract surgery (19.6%) were the most common facilitating factors. Conclusion: Proportion of bilaterally cataract blind people undergoing surgery and consequently SRR were low. The most common barriers were at the individual level while facilitating factors at the community level were instrumental in promoting uptake of services. Interventions involving community-based support for the blind may be useful in overcoming barriers to eye care.

INAHTA IMPACT STORY: LEGISLATIVE AND ACCREDITATION REQUIREMENTS FOR OFFICE-BASED SURGERY IN AUSTRALIA.

BACKGROUND: There is growing trend for some surgical procedures previously performed in hospitals to be done in alternative settings, including office-based facilities. There has been some safety concerns reported in the media, which document serious adverse events following procedures performed in an office-based setting. To understand the current regulatory oversight of surgery in this setting ASERNIP-S conducted a review of the legislative and accreditation process governing these facilities in Australia. METHODS: Using rapid review methodology, internet searches targeted government Web sites for relevant publicly-available documents. Use of consolidated versions of legislative instruments ensured currency of information. Standards were sourced directly from the issuing authorities or those that oversee the accreditation process. RESULTS: Within Australia, healthcare facilities for surgery and their licensing are defined by each state and territory, which results in significant jurisdictional variation. These variations relate to the need for anesthesia beyond conscious sedation and listing of procedures in legislative instruments. In 2013, Australia adopted National Safety and Quality Health Service standards (NSQHS standards) for the accreditation of hospitals and day surgery centers; however, there is no NSQHS standard for office-based facilities. The main legislative driver for compliance is access to reimbursement schemes for service delivery. CONCLUSIONS: The legislative and accreditation framework creates a situation whereby healthcare facilities that provide services outside the various legal definitions of surgery and those not covered by a reimbursement scheme, can operate without licensing and accreditation oversight. This situation exposes patients to potential increased risk of harm when receiving treatment in such unregulated facilities.

Patient satisfaction with the perioperative surgical services and associated factors at a University Referral and Teaching Hospital, 2014: a cross-sectional study.

INTRODUCTION: Globally, increasing consideration has been given to the assessment of patient satisfaction as a method of monitor of the quality of health care provision in the health institutions. Perioperative patient satisfaction has been contemplated to be related with the level of postoperative pain intensity, patients' expectation of the outcome, patient health provider relationship, inpatient services, hospital facilities, access to care, waiting time, cost and helpfulness of treatments received. The study aimed to assess the level of patient satisfaction with perioperative surgical services and associated factors. METHODS: Hospital based quantitative cross-sectional study was conducted in University of Gondar teaching hospital from April1-30, 2014. Structured Amharic version questionnaire and checklist used for data collection. All patients who operated upon during the study period were included. Both bivariate and multivariate logistic regression model used to identify the variables which had association with the dependent variable. P-values < 0.05 were considered statistically significant. RESULTS: Two hundred and seventy eight patients underwent surgery during the study period. Nine patients were excluded due to refusal to participate in the study. A total of 269 out of 278 patients were included in the study with a response rate of 96.8%. The overall level of patient satisfaction with perioperative surgical services was 98.1%. The variables that had association with the outcome variable from the multivariate analysis were patient admission status (AOR=0.073, CI=0.007-0.765, P=0.029), information about the disease and operation (AOR=0.010, CI=0.001-0.140, P=0.001) and operation theatre staff attention to the patients complains (AOR=0.028, CI=0.002-0.390, P=0.008) respectively. CONCLUSION: The level of patient satisfaction with perioperative surgical services was high compared with previous studies conducted in the country and other countries in the world. Health professionals need to give emphasis for information on care provision processes, patients' health progress and patients' complaints.

Retrospective review of Surgical Availability and Readiness in 8 African countries.

OBJECTIVES: The purpose of this study was to assess surgical availability and readiness in 8 African countries using the WHO's Service Availability and Readiness Assessment (SARA) tool. SETTING: We analysed data for surgical services, including basic and comprehensive surgery, comprehensive obstetric care, blood transfusion, and infection prevention, obtained from the WHO's SARA surveys in Sierra Leone, Uganda, Mauritania, Benin, Zambia, Burkina Faso, Democratic Republic of Congo and Togo. PRIMARY AND SECONDARY OUTCOME MEASURES: Among the facilities that were expected to offer surgical services (N=3492), there were wide disparities between the countries in the number of facilities per 100 000 population that reported offering basic surgery (1.0-12.1), comprehensive surgery (0.1-0.8), comprehensive obstetric care (0.1-0.8) and blood transfusion (0.1-0.8). Only 0.1-0.3 facilities per 100 000 population had all three bellwether procedures available, namely laparotomy, open fracture management and caesarean section. In all the countries, the facilities that reported offering surgical services generally had a shortage of the necessary items for offering the services and this varied greatly between the countries, with the facilities having on average 27-53% of the items necessary for offering basic surgery, 56-83% for comprehensive surgery, 49-72% for comprehensive obstetric care and 54-80% for blood transfusion. Furthermore, few facilities had all the necessary items present. However, facilities that reported offering surgical services had on average most of the necessary items for the prevention of infection. CONCLUSIONS: There are important gaps in the surgical services in the 8 African countries surveyed. Efforts are therefore urgently needed to address deficiencies in the availability and readiness to deliver surgical services in these nations, and this will require commitment from multiple stakeholders. SARA may be used to monitor availability and readiness at regular intervals, which will enable stakeholders to evaluate progress and identify gaps and areas for improvement.

A Literature Review on Validated Simulations of the Surgical Services.

The surgical department is a critical unit that oversees multiple surgical-based clinical pathways and works with various other units in a hospital. This department faces numerous challenges relating to variability in demand and management of resources. The aim of this article is to review the application of validated simulation models on hospital-wide surgical services. Each of these models is broadly classified by (i) simulation method and (ii) level of detail given to the management of "patient pathways" and "staff workflows". We remark that very few studies have given attention to the management of staff workflows in their validated simulation models.

Evaluation of the Community Cataract Surgical Services of a University Teaching Hospital Using Cataract Surgical Coverage in Nigeria.

BACKGROUND: Cataract is the leading cause of blindness in the world. An efficient and effective cataract surgical service is necessary to reduce the backlog of cataract blindness in the community. This study aims to determine the cataract surgical coverage among individuals aged 50 years and above residing in Esie and Arandun communities. This will serve as a measure of the impact of the cataract intervention programme provided by the University of Ilorin Teaching Hospital, Nigeria. METHODS: The study was a population-based, cross sectional survey conducted from November to December, 2013. Cataract surgical services are provided by the University of Ilorin Teaching Hospital, Nigeria, at Esie and Arandun communities as out-reach centres. Seven hundred and fifty-five individuals aged 50 years and above residing in these communities had basic ocular examination done. RESULTS: Out of the 765 subjects registered, 755(98.7%) were examined. Out of these, 38.4% were males and 61.6% were females. The prevalence of bilateral cataract blindness was 1.6%. The Cataract Surgical Coverage (eyes) at visual acuity < 3/60 for males and females were 52.3% and 51.2% respectively (X2=19.30, p=0.001), while the Cataract Surgical Coverage (person) at visual acuity less < 3/60 for males and females were 80.6% and 68.4% respectively (X2=2.10, p=0.147). CONCLUSION: The Cataract Surgical Coverage was high with a correspondingly low prevalence of cataract blindness in these communities. The availability of cataract surgical services via out-reach programmes bridges the gap between eye care-givers and the community.

The management of bladder exstrophy: the Manchester experience.

AIM: Bladder exstrophy (BE) is a severe congenital malformation with life-long implications. This article discusses the current surgical management and describes the development of the nationally commissioned bladder exstrophy service in Manchester, UK. METHODS: Outcome of BE surgery in Manchester was retrospectively reviewed. A Medline search was also undertaken and the published outcomes reviewed for the Modern Staged Repair of Bladder Exstrophy (MSRE), the Complete Primary Repair of Exstrophy (CPRE), and Radical Soft-Tissue Mobilisation (RSTM). RESULTS: Sixty-seven infants with BE were treated in the period 2000-2012. Twenty-six infants underwent primary closure during the neonatal period, and in twenty-one this was successful. The remaining forty-one infants underwent delayed closure, and all were successful. Twenty-six children underwent MSRE, and continence with urethral micturition was achieved in sixteen (62%) (ten alone and six with urethral clean intermittent catheterisation). A further five (19%) are continent following bladder neck closure, cystoplasty, and continent diversion. Seven (26%) of the twenty-six patients are completely dry overnight. Twenty infants underwent primary ureteric reimplantation, and none have renal scarring. By contrast, renal scarring (unilateral n=fourteen; bilateral n=five) was found in nineteen of thirty-seven infants who did not undergo reimplantation. CONCLUSIONS: Specialised experience has allowed demonstrable improvement in bladder exstrophy outcomes throughout the period of the study.