Prevalence of stroke-related risk factors in Albania: a single-center experience.

Introduction: Stroke, a prominent global cause of mortality and disability, is broadly categorized into ischemic and hemorrhagic types. An epidemiological survey of stroke and its risk factors can help identify individuals at higher risk and therefore promote stroke prevention strategies. The aim of this study was to estimate the current prevalence of stroke and evaluate stroke-associated risk factors in Albania. Material and methods: This was a single-center retrospective analysis conducted in Albania for the period from May 2015 to September 2021. Data were collected retrospectively through hospital records. Stroke was defined as sudden onset of a nonconvulsive and focal neurological deficit, and ischemic stroke was diagnosed using brain computed tomography (CT), magnetic resonance (MR) imaging, or both. We examined patient history characteristics encompassing demographics, stroke history, conventional vascular risk factors, and lifestyle-related risk factors. Results: The mean age of the 3860 patients was 74.6 ±10.4 years, and 73.5% were men. The prevalence of carotid stenosis, arrhythmia, obesity, and hypertension was significantly higher in males than in females (p < 0.001). Out of the 3860 patients in the study cohort, 641 (16.6%) subjects died, while 335 (8.7%) patients achieved complete recovery. Hemiparesis was observed in 386 (10%) patients and hemiplegia in 868 (22.4%) patients. Conclusions: Our analysis underscores the male predominance (2.2 : 1) in stroke cases. Carotid and vertebral artery stenosis is a significant factor, emphasizing the life-saving potential of early intervention. Social and economic factors in Albania pose challenges, demanding comprehensive strategies. Prospective trials are crucial to explore intervention efficacy, and timing, and address socioeconomic impacts on timely stroke management.

Direct-Acting Antiviral Treatment in Albanian Patients With Chronic Hepatitis C and Advanced Liver Fibrosis.

Background Treating chronic hepatitis C (CHC) with direct-acting antiviral (DAA) is very effective at clearing the infection. In Albania treatment with DAA is limited to patients with liver stiffness F3-F4, and with other co-infections. The objective of this study was to evaluate the efficacy of DAA in Albanian patients with genotypes 1-5, who mostly suffer from advanced liver fibrosis. Material and Methods This is a retrospective study carried out at the University Hospital Center "Mother Teresa", Tirana, during 2014-2019, including treatment-naïve and treatment-experienced patients with genotypes 1-5. All patients were evaluated with elastography and most of them were F3-F4. The primary endpoint involved the patients achieving SVR-12, or undetectable hepatitis C virus/ribonucleic acid (HCV RNA) 12 weeks after the end of treatment. In patients without a genotype, we have used a pangenotypic regimen. Results This study included 207 patients with a mean age of 48.9 ± 13.1 years, 56% male and 44% female; 152 (73%) were genotype 1, 24 were (11.5%) genotype 2, nine were (4.3%) genotype 3, 14 were (6.7%) genotype 4, one was (0.4%) genotype 5, and seven (3.8%) unassigned genotypes. The sustained virologic response (SVR) percentage according to genotype is discussed in the article. The overall SVR score of all the patients in our study was >93%. According to elastography, 127 (66%) were F3-F4, and 80 (38.6%) were F1-F2. Conclusion Treatment with DAA proved to be very effective in our patients; most of them had advanced liver fibrosis as well as compensated or decompensated liver cirrhosis. The overall SVR score of the patients in our study was >93%. Our country needs to treat all patients with chronic hepatitis C without limitations to attain the WHO objective of eradicating this disease by 2030.

Pneumoperitoneum After a Redo Cardiac Surgery: Patience Can Lead to Victory.

Pneumoperitoneum after cardiac surgery is not usual. It occurs during extended sternotomy, which is sometimes accompanied by the opening of the peritoneal cavity or in cases after previous sternotomies. A 73-year-old man was operated on two times within one month due to prosthetic mitral valve dehiscence. The second operation was accompanied by a lot of complications, including blood loss, respiratory failure, massive pleural effusion, sternal infection, pneumomediastinum, and pneumoperitoneum. The presence of pneumoperitoneum alerted the possibility of intra-abdominal cavitary organ perforation. No surgical approach was chosen because there were no signs of peritonitis. The patient was discharged to home in a good health situation. Sixteen months later, he was recovered at the hospital for heart failure, and after abdominal CT, benign pneumoperitoneum was observed in the abdominal cavity again. There was no explanation for this finding, but again conservative treatment was chosen. He was discharged for the third time from the hospital in good condition.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA).

INTRODUCTION: No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. MATERIAL AND METHODS: A prospective analysis of adult patients enrolled in the IROA. RESULTS: Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. CONCLUSION: Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Raising concerns about the Sepsis-3 definitions.

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients.

BACKGROUND: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. METHODS: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. RESULTS: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. CONCLUSION: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey.

BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

Erratum to: IROA: International Register of Open Abdomen, preliminary results.

[This corrects the article DOI: 10.1186/s13017-017-0123-8.].

IROA: International Register of Open Abdomen, preliminary results.

BACKGROUND: No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA). METHODS: A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org. RESULTS: Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male; Mean BMI: 36±5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016). Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days. CONCLUSION: Temporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results. TRIAL REGISTRATION: ClinicalTrials.gov NCT02382770.

Teaching Advanced Trauma Life Support (ATLS): A nationwide retrospective analysis of 8202 lessons taught in Germany.

OBJECTIVE: To examine whether faculty who teach the Advanced Trauma Life Support (ATLS) course would improve with experience and, correspondingly, ratings from course evaluations would increase. DESIGN: Retrospective analysis of student evaluations of 262 ATLS courses held between 2008 and 2012. SETTING: All ATLS courses held between 2008 and 2012 nationwide in Germany. PARTICIPANTS: All ATLS student course evaluations covering 8202 lessons, 81 instructors, 36 course directors, and 5 coordinators. RESULTS: ATLS courses in Germany attained high levels of student satisfaction. Satisfaction levels increased steadily over the 5-year period studied. The entire staff influenced this finding. Teaching quality improved the most within the first 100 lessons taught. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats. The 2 demonstrations that open the course were the top rated events. Skill stations, including a human phantom, were highly rated; the cricothyrotomy station was top rated. CONCLUSION: The German ATLS course evaluations indicated steady improvement over the 5-year study. The level of experience of course coordinators, directors, and instructors influenced this finding. Teaching quality improved most within the first 100 lessons taught, and then reached a steady state. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats.

The readiness of emergency and trauma care in low- and middle-income countries: a cross-sectional descriptive study of 42 public hospitals in Albania.

BACKGROUND: Traumatic injuries have become a substantial but neglected epidemic in low- and middle-income countries (LMICs), but emergency rooms (ERs) in these countries are often staffed with healthcare providers who have minimal emergency training and experience. The aim of this paper was to describe the specialized training, available interventions, and the patient management strategies in the ERs in Albanian public hospitals. METHODS: A cross-sectional descriptive study of 42 ERs in the Republic of Albania between September 5, 2014, and December 29, 2014 was performed. Assessment subcategories included the following: (1) specialized training and/or certifications possessed by healthcare providers, (2) interventions performed in the ER, and (3) patient management strategies. RESULTS: Across the 42 ERs surveyed, less than half (37.1-42.5 %) of physicians and one third of nurses (7.1-26.0 %) working in the ERs received specialized trauma training. About half (47.9-57.1 %) of the ER physicians and one fifth of the nurses (18.3-22.9 %) possessed basic life support certification. This survey demonstrated some significant differences in the emergency medical care provided between primary, secondary, and tertiary hospitals across Albania (the significance level was set at 0.05). Specifically, these differences involved spinal immobilization (p = 0.01), FAST scan (p = 0.04), splinting (p = 0.01), closed reduction of displaced fractures (p = 0.02), and nurses performing cardiopulmonary resuscitation (CPR) (p = 0.01). Between 50.0 and 71.4 % of the facilities cited a combined lack of training and supplies as the reason for not offering interventions such as rapid sequence induction, needle thoracotomy, chest tube insertion, and thrombolysis. Mass casualty triage was utilized among 39.1 % primary hospitals, 41.7 % of secondary, and 28.6 % of tertiary. CONCLUSIONS: The emergency services in Albania are currently staffed with inadequately trained personnel, who lack the equipment and protocols to meet the needs of the population.

Access to Specialized Care Through Telemedicine in Limited-Resource Country: Initial 1,065 Teleconsultations in Albania.

OBJECTIVE: To analyze the initial experience of the nationwide clinical telemedicine program of Albania, as a model of implementation of telemedicine using "Initiate-Build-Operate-Transfer" strategy. METHODS: This was a retrospective study of prospectively collected data from teleconsultations in Albania between January 1, 2014 and August 26, 2015, delivered synchronously, asynchronously, or a combination of both methods. Patient's demographics, mode of consultation, clinical specialty, hospitals providing referral and consultation, time from initial call to completion of consultation, and patient disposition following teleconsultation were analyzed. Challenges of the newly created program have been identified and analyzed as well. RESULTS: There were 1,065 teleconsultations performed altogether during the study period. Ninety-one patients with autism managed via telemedicine were not included in this analysis and will be reported separately. Of 974 teleconsults, the majority were for radiology, neurotrauma, and stroke (55%, 16%, and 10% respectively). Asynchronous technology accounted for nearly two-thirds of all teleconsultations (63.7%), followed by combined (24.3%), and then synchronous (12.0%). Of 974 cases, only 20.0% of patients in 2014 and 22.72% of patients in 2015 were transferred to a tertiary hospital. A majority (98.5%) of all teleconsultations were conducted within the country itself. CONCLUSIONS: The Integrated Telemedicine and e-Health program of Albania has become a useful tool to improve access to high-quality healthcare, particularly in high demanding specialty disciplines. A number of challenges were identified and these should serve as lessons for other countries in their quest to establish nationwide telemedicine programs.

Telemedicine as an innovative model for rebuilding medical systems in developing countries through multipartnership collaboration: the case of Albania.

The U.S. Government and other developed nations provide billions of dollars annually in relief assistance to countries around the world. The long-term benefits of this aid, however, are often difficult to elucidate. The aim of this article is to present a model of a multipartnership collaboration among U.S. governmental, nongovernmental organizations, and academia to rebuild medical systems using telemedicine as a sustainable model of foreign aid. The International Virtual e-Hospital implemented the "initiate-build-operate-transfer" strategy to establish an effective telemedicine system in Albania that includes the National Telemedicine Center and 12 regional telemedicine centers. This nationwide telemedicine network has active clinical programs, virtual educational programs, and an electronic library that has substantially improved the access to care while advancing medical education. We propose that telemedicine is an optimal, sustainable, low-cost model for rebuilding medical systems of developing countries when implemented through a multipartnership approach.

Trauma system evaluation in developing countries: applicability of American College of Surgeons/Committee on Trauma (ACS/COT) basic criteria.

BACKGROUND: Trauma continues to be a major health problem worldwide, particularly in the developing world, with high mortality and morbidity. Yet most developing countries lack an organized trauma system. Furthermore, developing countries do not have in place any accreditation process for trauma centers; thus, no accepted standard assessment tools exist to evaluate their trauma services. AIM: The aims of this study were to evaluate the trauma system in Albania, using the basic trauma criteria of the American College of Surgeons/Committee on Trauma (ACS/COT) as assessment tools, and to provide the Government with a situational analysis relative to these criteria. MATERIALS AND METHODS: We used the ACS/COT basic criteria as assessment tools to evaluate the trauma system in Albania. We conducted a series of semi-structured interviews, unstructured interviews, and focus groups with all stakeholders at the Ministry of Health, at the University Trauma Hospital (UTH) based in Tirana (the capital city), and at ten regional hospitals across the country. RESULTS: Albania has a dedicated national trauma center that serves as the only tertiary center, plus ten regional hospitals that provide some trauma care. However, overall, its trauma system is in need of major reforms involving all essential elements in order to meet the basic requirements of a structured trauma system. CONCLUSION: The ACS/COT basic criteria can be used as assessment tools to evaluate trauma care in developing countries. Further studies are needed in other developing countries to validate the applicability of these criteria.