The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures.

OBJECTIVES: The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia. DESIGN: A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups. RESULTS: A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia. CONCLUSION: The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.

Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards.

BACKGROUND: Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD: An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS: Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION: Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone.

INTRODUCTION: Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS: The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION: The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.

Headache in sleep apnea syndrome: epidemiology and pathophysiology.

This review investigates the relation between obstructive sleep apnea and sleep apnea headache, migraine and tension-type headache. Focus is made on studies from the general population with interviews conducted by a physician and obstructive sleep apnea confirmed by polysomnography. Obstructive sleep apnea syndrome is observed in 3% of the middle-aged population. The prevalence of sleep apnea headache in this population is 12%-18%, while morning headache with similar symptomatology as sleep apnea headache occur in 5%-8% of the general population. People with sleep apnea headache did have significantly more minutes below 90% oxygen saturation (23.1 min vs. 1.9 min, p = 0.002), higher level of average oxygen desaturation (5.9% vs. 4.5%, p < 0.001) and lower average of the lowest oxygen saturation (80.9% vs. 88.5%, p < 0.001) than people with morning headache. A comparison of those with obstructive sleep apnea with or without sleep apnea headache showed no significant differences. Thus, oxygen desaturation alone cannot explain the pathophysiology of sleep apnea headache. Obstructive sleep apnea and migraine, and obstructive sleep apnea and tension-type headache are not related in the general population. The cause of sleep apnea headache remains to be elucidated.

Change in smoking status during two consecutive pregnancies: a population-based cohort study.

OBJECTIVE: To investigate changes in tobacco smoking in two consecutive pregnancies and factors associated with the change. DESIGN: Population-based cohort study. SETTING: New South Wales, Australia, 2000-10. POPULATION: A total of 183,385 women having first and second singleton pregnancies. METHODS: Descriptive and multivariable logistic regression analyses of perinatal data linked to hospital admission data. MAIN OUTCOME MEASURES: Proportion of women smoking during their first pregnancy who quit by their second, and of women not smoking in their first pregnancy who did smoke during their second. RESULTS: Among 22,761 smokers in the first pregnancy, 33.5% had quit by their second. Among 160,624 non-smokers in their first pregnancy, 3.6% smoked during their second. Women who were aged ≥25 years, were married, born in a non-English speaking country, used private obstetric care, and lived in a socio-economically advantaged area were more likely to quit or less likely to start smoking in the second pregnancy. Smokers who had gestational hypertension (adjusted odds ratio [OR] 1.36, 95% confidence interval [95% CI] 1.23-1.51), a large-for-gestational-age infant (OR 1.66, 95% CI, 1.46-1.89), and a stillbirth (OR 1.44, 95% CI 1.06-1.94) were more likely to quit, whereas smokers whose infant was small-for-gestational-age (OR 0.65, 95% CI 0.60-0.70) or admitted to special care nursery (OR 0.87, 95% CI 0.81-0.94) were less likely to quit. Among non-smokers in the first pregnancy, the risk of smoking in the second pregnancy increased with late antenatal attendance (e.g. ≥26 weeks, OR 1.30, 95% CI 1.14-1.48), gestational diabetes (OR 1.25, 95% CI 1.07-1.45), preterm birth (e.g. spontaneous, OR 1.25, 95% CI 1.10-1.43), caesarean section (e.g. prelabour, OR 1.13, 95% CI 1.01-1.26), and infant small-for-gestational-age (OR 1.37, 95% CI 1.26-1.48) or required special care nursery (OR 1.14, 95% CI 1.06-1.23). Inter-pregnancy interval of ≥3 years was associated with either change in smoking status. CONCLUSIONS: Most smokers continue to smoke in their next pregnancy, even among those who experienced poor outcomes. Intensive interventions should be explored and offered to women at the highest risk.

Type D personality is associated with increased prevalence of ventricular arrhythmias in community-residing persons without coronary heart disease.

BACKGROUND: Type D personality may be a risk factor for poor outcome in patients with cardiovascular disease. The biological mechanisms underlying this association are poorly understood. The objective of the study was to test the hypotheses that Type D personality is associated with biological markers for sympathetic dysregulation. DESIGN: Cross-sectional community-based study. METHODS: Type D personality was evaluated by DS-14 in 450 persons (46% men), aged between 30 and 65 years. From a Holter-recording, (mean length 18.3 hours), long-term heart rate, ventricular arrhythmias, and heart rate variability (HRV) were registered as markers of sympathetic dysregulation. Traditional cardiovascular risk factors, apnoea-hypopnoea index, medication, and anxiety symptoms were adjusted for. RESULTS: Type D persons had higher long-term averaged heart rate (74 vs. 71 beats/min, p = 0.003), but this difference was attenuated and not significant in the multivariate model (p = 0.078)). There was an increased prevalence of complex ventricular ectopy (bigeminy, trigeminy, or non-sustained ventricular tachycardia; 14 vs. 6%, p = 0.005 in multivariate model). HRV indices did not differ significantly between those with or without Type D personality. Anxiety symptoms did not confound these associations. CONCLUSIONS: Type D personality is independently associated with a higher likelihood of ventricular arrhythmias, which may be implicated in the increased cardiovascular risk observed in persons with Type D personality.

Novel cardiovascular risk markers in depression: no association between depressive symptoms and osteoprotegerin or adiponectin in persons at high risk for sleep apnea.

BACKGROUND: Inflammation is believed to play a role in the pathogenesis of both cardiovascular disease and depressive disorders. We hypothesized that circulating concentrations of the novel inflammatory and cardiovascular biomarkers osteoprotegerin (OPG) and adiponectin as well as high sensitivity C-reactive protein (hsCRP) are associated with the severity of depressive symptoms and presence of major depressive disorder (MDD). METHODS: In a cross-sectional population-derived study (Akershus Sleep Apnea Project) 520 persons underwent clinical examination and venous blood sampling. Medical history was obtained and the participants completed the Beck Depression Inventory (BDI). Structured clinical interviews for axis-I disorders including MDD were performed in a subgroup of 288 participants. OPG and adiponectin concentrations were determined by in-house time-resolved immunofluorometric assays. RESULTS: Despite significant correlation with hsCRP (r=0.162, p<0.001), the sum-score of BDI did not correlate with OPG or adiponectin levels (r=0.011, p=0.811 and r=0.055, p=0.210, respectively). Neither circulating OPG nor adiponectin differed between persons with (n=34) and without (n=246) MDD (median±interquartile range: 1.18 (0.96-1.49) vs. 1.17 (0.93-1.57) ug/l and 7.26 (5.13-9.91) vs. 7.39 (5.23-11.37) mg/l, respectively). LIMITATIONS: Causal considerations are not possible, and results in the sub-group of diagnosed participants need careful interpretation due to small sample size. CONCLUSIONS: hsCRP was independently associated with depressive symptoms, but no association between depression severity or presence of MDD and OPG- or adiponectin concentrations was observed in community-residing persons at high risk for obstructive sleep apnea.

Prevalence of cardiovascular risk factors and concentration of C-reactive protein in Type D personality persons without cardiovascular disease.

BACKGROUND: Type D personality is associated with poor cardiovascular outcome in patients with coronary or peripheral arterial disease. Whether Type D personality is associated with cardiovascular risk in persons without overt cardiovascular disease remains unknown. We hypothesized that Type D personality is associated with higher prevalence of traditional cardiovascular risk factors and higher concentration of C-reactive protein. DESIGN: Cross-sectional study. METHODS: Type D personality was assessed in 453 participants without cardiovascular disease derived from an epidemiological study of obstructive sleep apnoea. An evaluation of obesity, lipid status, diabetes, blood pressure, heart rate, smoking, leisure-time physical activity and high-sensitivity C-reactive protein was performed. RESULTS: Smoking (43% vs. 21%, P < 0.001) and low leisure-time physical activity (<3 hours/week, 57% vs. 40%, P = 0.003) were more prevalent, and heart rate (mean (standard deviation), 75 (10) vs. 71 (9), P = 0.001) and body mass index was higher (29.8 (6.0) vs. 28.4 (4.5) kg/m2, P = 0.009) in Type D compared to non-Type D participants. The total number of risk factors was significantly higher in Type D than non-Type D participants (3.4 (1.3) vs. 3.0 (1.2), P = 0.004). The concentration of C-reactive protein was higher in participants with Type D personality (median, interquartile range 1.6, 0.7-3.4 vs. 1.1, 0.6-2.6, P = 0.047), although not statistically significant after adjustment for possible mediating factors. CONCLUSIONS: Among participants at high risk of cardiovascular disease, presence of Type D personality was associated with elevated body mass index and unhealthy behaviour such as smoking and low physical activity, which may have mediated the elevated concentration of C-reactive protein.

The prevalence and characteristics of alcohol-related presentations to emergency departments in rural Australia.

BACKGROUND: The burden of harm associated with alcohol misuse is disproportionately high in rural areas of Australia, and a considerable proportion of this burden is borne by the health system. The health impact of alcohol in rural areas has been measured in terms of the contribution of alcohol to hospital inpatient admissions and mortality rates, despite many more alcohol-related cases presenting to emergency departments (EDs). This study aims to estimate the proportion of presentations to EDs in rural Australia that are alcohol-related and to identify the associated patient and presentation characteristics. METHODS: Patients aged ≥14 years presenting to four EDs in rural NSW were assessed on two measures: (1) Clinician judgement of alcohol consumption, and (2) patient self-report of alcohol consumption in the 6 h preceding the onset of their condition. RESULTS: Preliminary analyses revealed sample selection biases in two of the EDs, and these samples were consequently excluded from further analyses. In the two remaining EDs, 46% of presentations were assessed, of which 9% were identified as alcohol-related. Presentations for mental disorders, those with more urgent triage categories and those occurring on weekends or at night were more often alcohol-related. CONCLUSIONS: The prevalence of alcohol-related ED presentations observed was at the lower end of the documented range, probably due to methodological differences and limitations, as well as geographic variation. Despite this, alcohol-related presentations were associated with a substantial impact on the ED. Policies and programs to reduce the impact of alcohol on rural emergency departments are needed.

A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP).

The Berlin Questionnaire (BQ) is a widely used screening tool for obstructive sleep apnea (OSA), but its performance in the general population setting is unknown. The prevalence of OSA in middle-aged adults is not known in Norway. Accordingly, the aims of the current study were to evaluate the utility of the BQ for OSA screening in the general population and to estimate the prevalence of OSA in Norway. The study population consisted of 29,258 subjects (aged 30-65 years, 50% female) who received the BQ by mail. Of these, 16,302 (55.7%) responded. Five-hundred and eighteen subjects were included in the clinical sample and underwent in-hospital polysomnography. Screening properties and prevalence were estimated by a statistical model that adjusted for bias in the sampling procedure. Among the 16,302 respondents, 24.3% (95% confidence interval (CI)=23.6-25.0%) were classified by the BQ to be at high-risk of having OSA. Defining OSA as an apnea-hypopnea index (AHI) ≥5, the positive predictive value of the BQ was estimated to be 61.3%, the negative predictive value 66.2%, the sensitivity 37.2% and the specificity 84.0%. Estimated prevalences of OSA were 16% for AHI≥5 and 8% for AHI≥15. In conclusion, the BQ classified one out of four middle-aged Norwegians to be at high-risk of having OSA, but the screening properties of the BQ were suboptimal. The estimated prevalence of OSA was comparable to previous estimates from general populations in the USA, Australia and Europe.

[From prison with coma]. / I koma frå fengselet.

A 42-year-old man was found unconscious in his prison cell. Investigations revealed non-recognized diabetes mellitus, possibly secondary to use of prescribed antipsychotic drugs. Second generation antipsychotics are associated with metabolic changes such as weight gain, hyperglycaemia and dyslipidaemia. Severe side effects may also occur; e.g. diabetic ketoacidosis in people without acknowledged diabetes (as presented in this case report). Providing adequate healthcare to people with psychotic disorders may be a demanding task. When these patients develop somatic conditions, a multidisciplinary approach is required. Personnel from many specialities may become involved, and they are not all familiar with drugs commonly used to treat psychiatric disorders or how to deal with their side effects. Several guidelines addressing these problems have been issued during the last years. Norwegian guidelines should aid clinicians in decision-making when confronted with these dilemmas.

[Profylactiv cholesystectomy after bile duct stones?]. / Profylaktisk kolecystektomi etter gallegangsstein?

BACKGROUND: Endoscopic sphincterotomy (EPT) is well established as a treatment of bile duct stones, often performed to reduce the frequency of complications. We wanted to evaluate the complication rates after preventive cholecystectomy compared with expectative follow up. MATERIAL AND METHODS: In this retrospective study we have registered the outcome for 63 patients treated with cholecystectomy and 298 patients followed up expectatively. Allocation to the groups was based on clinical evaluation without randomization, hence the groups are not similar, a fact which should be taken into consideration when results are evaluated. For both groups we have registered events due to biliary complications. RESULTS: The patients submitted to cholecystectomy were somewhat younger with higher comorbidity than the non-operated patients. In the expectative group, 27% had one or more late complications as opposed to 6.3% in the cholecystectomy group. There was no relative difference in mortality. INTERPRETATION: The study confirms that prophylactic cholecystectomy may actually contribute to a lower complication rate and is an option for treatment in low-risk patients. Prophylactic cholecystectomy cannot, however, be recommended as a routine procedure. The study is based on clinically selected patient groups and results must be interpreted with care.

Haemotoxicity of thiamphenicol in the BALB/c mouse and Wistar Hanover rat.

Chloramphenicol (CAP) is haemotoxic in man, inducing two forms of toxicity. First, a commonly-occurring, dose-related, reversible bone marrow depression, which develops during treatment. Second, a rarer aplastic anaemia (AA), developing after treatment, is irreversible, and often fatal. Thiamphenicol (TAP) was developed as a replacement for CAP; however, there are no toxicological investigations in the mouse or rat on the dose-related haemotoxicity of TAP, in repeat dose gavage studies. Therefore, we have conducted a comprehensive investigation in these species, administering TAP for 7-17 days, to define haematological changes. Female BALB/c mice were gavaged with TAP, daily for 7-17 days at 400-1500 mg/kg; female Wistar Hanover rats were dosed with TAP daily at 50-375 mg/kg for 9 or 10 days. Haematological changes were studied at 1, 7 and 14 days post-dosing. In mice at day 1, TAP caused decreases in RBC, HCT and Hb; reticulocytes and platelets were reduced; changes were dose-related and reversible. Marrow cell counts were reduced; marrow was hypocellular, with erythroid depletion and progenitor cell vacuolation; the myeloid/erythroid (M:E) ratio was increased. In the rat, changes were not as clear-cut; there was anaemia with indications of reduced reticulocyte and platelet counts, and evidence of decreased neutrophils and lymphocytes. Marrow erythroid cells were decreased, precursor cells vacuolated, and the M:E ratio increased. We conclude that TAP induced haematological changes in the mouse and rat, parallelling the dose-dependent, reversible marrow depression reported in man; TAP is more haemotoxic in the rat than in the mouse.

Studies on the haemotoxicity of chloramphenicol succinate in the Dunkin Hartley guinea pig.

In man, chloramphenicol (CAP), induces two major haemotoxic effects. First, a reversible, dose-related reticulocytopenia and anaemia developing during treatment. Second, a non-dose-related aplastic anaemia (AA), developing weeks after treatment, is often irreversible and fatal. In previous studies, we developed a mouse model of the reversible reticulocytopenia/anaemia using CAP succinate (CAPS); attempts to induce AA in the mouse with CAPS were unsuccessful; in the rat, CAPS induced only minimal haemotoxicity. We therefore wished to investigate haematological changes caused by CAPS in a third rodent, particularly in relation to the induction of significant 'late stage' bone marrow depression (AA). Female guinea pigs were gavaged with CAPS in three experiments. In a dose ranging study, CAPS (at 2500 and 3500 mg/kg) was administered daily for 9 days, and blood examined at 1 day post dosing. CAPS induced increased erythrocyte values (an apparent haemoconcentration effect), and reduced reticulocytes and femoral marrow nucleated cell counts (FNCC). In a second experiment, CAPS was given at 333, 666 and 1000 mg/kg (13 days); haematological changes were compared with results from the initial study, with evidence of dose-related effects. In a final experiment, CAPS was administered (825 mg/kg, 16 days) and blood studied at 1, 12, 28 and 63 days post dosing. At day 1, erythrocyte values were decreased (NS), and reticulocytes and FNCC were reduced; the marrow was hypocellular with erythroid depletion. At 12 and 28 days, values returned towards the normal range. At 63 days, parameters were normal. Thus, CAPS (825 mg/kg for 16 days) induced changes comparable to the reversible bone marrow depression seen in man; but there was no evidence of 'late stage' (i.e. at 63 days) marrow depression, as would be seen in a developing or overt marrow aplasia (AA). The guinea pig (like the mouse) is a model for the early events, but is not a good model for CAP-induced AA in man.

An assessment of chloramphenicol and thiamphenicol in the induction of aplastic anaemia in the BALB/c mouse.

The potential of the antibiotics chloramphenicol succinate (CAPS) and thiamphenicol (TAP) to induce aplastic anaemia in the female BALB/c mouse was investigated. CAPS was administered at 2000 mg/kg, and TAP at 850 mg/kg, daily by gavage, for 17 days. At 1, 13, 22, 41, 98 and 179 days after the final dose of each antibiotic, mice (n = 4 or 5) were sampled for haematological examination and haematopoietic stem cell assays. Both CAPS and TAP induced significant reductions in red blood cell count, haematocrit and haemoglobin values at day 1 post dosing; counts of colony-forming units-erythroid and colony-forming units-granulocyte-macrophage, were similarly significantly decreased at this time. All these reduced parameters returned towards normal at days 13 and 22. At days 41, 98 and 179, results for all haematological values and stem cell assays in both CAPS- and TAP-treated mice compared with the controls; there was no evidence of a reduction in peripheral blood values or bone marrow parameters at the later sampling points, as would be expected in a developing or overt bone marrow aplasia. We therefore consider that the administration of CAPS and TAP, which have been associated with the development of aplastic anaemia in man, induce a reversible anaemia, but not a chronic bone marrow aplasia, when given at haemotoxic dose levels for 17 days in the BALB/c mouse.

Technical report: the post-micturition CT scan as an aid to staging bladder cancer.

The accurate staging of bladder cancer by computed tomography (CT) can be hampered where a bowel loop lies in close proximity to a tumour and the resolution of the system is such that a clearly defined fat plane between tumour and bowel is not visible. This paper describes the use of post-micturition scanning in a case where bowel involvement by tumour was suspected on the initial scans but was subsequently shown to be absent on the post-micturition scans. This technique has the potential, in selected cases, to reduce a CT staging from T4 to T3 or less.

Magnetic resonance behaviour of lipiodol.

Lipiodol is a frequently used contrast agent for lymphangiography and more recently has been used in the investigation of hepatoma. We describe the magnetic resonance characteristics of lipiodol using a Siemens 1.5 T Magnetom with reference to the appearance and behaviour of lipiodol in abdominal lymphadenopathy. The characteristics described differ from previously published reports.