Global disease burden of conditions requiring emergency surgery.

BACKGROUND: Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden. METHODS: This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data. RESULTS: In the index year of 2010, there were 896,000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24.3 versus 10.6 deaths per 100,000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100,000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100,000 inhabitants. CONCLUSION: The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.

Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery.

OBJECTIVE: Nonphysicians in Mozambique have been performing major surgery for more than 20 years, with documented outcomes equivalent to those of specialists. The purpose of this study was to make an inventory of all government hospitals so as to document obstetric surgery performed by 'técnicos de cirurgia' (TCs) and to elucidate their retention at district level. DESIGN: Cross-sectional study of surgical procedures during 2002; longitudinal study of TCs and doctors graduating in 1987, 1988 and 1996. SETTING: All 34 hospitals with an operating theatre in Mozambique. POPULATION: Records of 12,178 major surgical obstetric operations were examined, and 59 medical officers and 34 TCs were interviewed. METHODS: Analysis of all surgical registers during 2002 in all government rural, provincial, general and central hospitals in Mozambique. TCs and doctors who had graduated in the specified years were traced and interviewed; health ministry records were reviewed to confirm assignments. MAIN OUTCOME MEASURES: Proportion of major obstetric surgeries performed by TCs. Proportion of TCs and medical doctors still at rural/district level at 7 years after graduation. RESULTS: Major obstetric surgery is conducted by nonphysicians in 57% of the 12,178 operations scrutinised. In district hospitals, they conducted 92% of 3246 operations. Retention of TCs and medical doctors at district hospital level differed markedly: after 7 years, 88% of the TCs remained in post compared with none of the medical doctors. CONCLUSION: Nonphysicians, trained in surgery, do most of the emergency obstetric surgery in Mozambique, and almost all of that performed in district hospitals. Nonphysicians, compared with physicians, stay longer in rural areas. After 7 years, around 90% of nonphysicians are still working in district hospitals, while almost no physicians remain there.

A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care.

Mortality has improved dramatically in most of South Asia as a consequence of modest economic improvement, better nutrition and a combination of health education, immunization, family planning and home treatment of certain common diseases, especially diarrhea and respiratory infections. However, death rates are still much higher than in parts of the world with fully developed health services and residual mortality is largely due to conditions which require very basic hospital services such as surgery for complications of pregnancy, infections and trauma, transfusion, intravenous fluids, oxygen and intensive antibiotics. All of these can be made available in very simple and unsophisticated hospital facilities. It has generally been assumed that the cost of such facilities would be high, and cost effectiveness much less than that of preventive, educational and home care programs. In 1995, our 50 bed hospital in rural Bangladesh had a cost per patient-day of 525 Bangladesh Takas (US dollars 13.15) and a cost per capita for the population served of 25 Takas (US dollars 0.62) per year. Every month 180 patients were admitted, one-third with clearly life-threatening or disabling conditions which could be successfully treated in such a facility. We adapted the Disability Adjusted Life Year (DALY) method of cost effectiveness analysis to calculate the DALYs (years of disability-free life) preserved for individual patients during a 3-month period, using what we considered to be very conservative estimates of the threat to life and the efficacy of treatment. The total cost of all hospital activities over the 3 months was divided by the sum of the DALYS for those patients who were successfully treated for clearly life threatening or disabling conditions, to give a cost per DALY of 437 Takas (US dollars 10.93). This compares favorably with estimates by others of a cost per DALY of US dollars 30 for measles immunization, 20 for acute lower respiratory infection detection and home treatment, or 2 for tetanus immunization of pregnant women. Sixty-two percent of the DALYS saved came from emergency obstetric care (EmOC) related activities. We conclude that cost effective basic hospital service can be added to immunization, family planning and other basic health services now available in countries like Bangladesh with a very low increase in total cost and that the benefits which would accrue, particularly for maternal and perinatal mortality, would be great.

Efficient and effective emergency obstetric care in a rural Indian community where most deliveries are at home.

OBJECTIVES: Most life threatening obstetric complications require hospital treatment to avert maternal mortality. Some assume that in developing countries hospital service for the poor must be in government hospitals and that a large proportion of deliveries needs to be in these hospitals to provide timely access to emergency care. This presents a major problem in countries like India, where almost all rural deliveries are at home and accessible government hospitals generally do not provide surgical treatment for obstetric emergencies. The study's objective was to determine obstetric outcomes, patterns and costs of obstetric care in a part of rural Maharashtra, India, where obstetric outcomes appear relatively good even though most deliveries are at home and government hospitals do not provide emergency obstetric care (EmOC). METHODS: 2905 pregnancies were identified and followed to term to learn the number and types of complications, where these complications were treated, how many women received EmOC and how these services affected outcome. RESULTS: Eighty-five percent of 2861 deliveries after 24 weeks were at home. A total of 14.4% of deliveries after 24 weeks had identified complications. Of these complicated deliveries, 78.9% were in a hospital. Forty-eight percent of hospital deliveries were in a private hospital, 35% in our project hospital and 18% in a government hospital. Hospitalized patients with obstetric complications constituted 11.4% of all deliveries. The cesarean section rate for all deliveries was 2.0%. Twenty-two of the cesareans were in private hospitals, 32 in our hospital and four in a government hospital. Hospital case fatality (deaths of mothers with identified complications) was 0.3%. Overall case fatality was 0.5%. However, there were only two maternal deaths from obstetric causes (70 per 100,000 live births), making these rates less than robust. The perinatal mortality rate was 36 per thousand live and still births. These outcome and process indicators are better than those reported in most of India, but both maternal deaths could have been prevented by early referral to hospital and 64% of perinatal deaths were to infants delivered at home. CONCLUSIONS: A network of private clinics with a voluntary, low cost hospital is providing effective EmOC in a remote rural area at very low per capita cost in the absence of easily accessible government service and with only 15% of deliveries in hospitals. Charges are low but low per capita cost is primarily due to intelligent self-selection of patients who need hospital care. Even though overall cost is low, cost is still an important barrier for many poor families. Improving the purchasing power of poor families through insurance or subsidy could be a more effective way to improve EmOC than trying to improve inadequate government facilities.

Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis.

For reasons not yet determined, chronic liver disease (CLD) has been a leading cause of excess morbidity and mortality in central Harlem. We conducted a case series and case-control analysis of demographic, clinical, epidemiological, and alcohol-intake-related information from patients with CLD and age- and sex-matched hospitalized control patients. Patients' sera were tested for markers of viral hepatitis. The presumed etiology of CLD among case-patients was as follows: both alcohol abuse and hepatitis C virus (HCV) infection, 24 persons (46% of case-patients); alcohol abuse alone, 15 (29%); HCV infection alone, 6 (12%); both alcohol abuse and chronic hepatitis B virus (HBV) infection, 3 (6%); and 1 each (2%) from: 1) schistosomiasis, 2) sarcoidosis, 3) unknown causes, and 4) alcohol abuse, chronic HBV, and HCV combined. In the case-control analysis, patients who had both alcoholism and either HBV (odds ratio [OR]: 6.3; 95% CI: 0. 5-334) or HCV (OR: 2.9; 95% CI: 1.3-6.2) were at increased risk for CLD, whereas patients who had only one of these three factors were not at increased risk for CLD. Patients who tested positive for the hepatitis G virus (HGV) did not have a significantly increased risk of CLD, and neither severity of CLD nor mortality was greater among these patients. Most patients in central Harlem who had CLD had liver damage from a combination of alcohol abuse and chronic viral hepatitis. Alcohol and hepatitis viruses appear to be synergistically hepatotoxic; this synergy appears to explain both the high rate of CLD in central Harlem and the recent reductions in this rate. Persons at risk for chronic HBV and HCV infection should be counseled about their increased risk of CLD if they consume excessive alcohol. Morbidity and mortality from liver disease could be decreased further by a reduction in alcohol consumption among persons who have chronic HBV and HCV infection, avoidance of needle sharing, and hepatitis B vaccination.

Redraping the inferior orbicularis arc.

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.

Contribution of smoking to excess mortality in Harlem.

The New York City neighborhood of Harlem has mortality rates that are among the highest in the United States. In absolute numbers, cardiovascular disease and cancer account for the overwhelming majority of deaths, especially among men, and these deaths occur at relatively young ages. The aim of this research was to examine self-reported smoking habits according to measures of socioeconomic status among Harlem men and women, in order to estimate the contribution of tobacco consumption to Harlem's remarkably high excess mortality. During 1992-1994, in-person interviews were conducted among 695 Harlem adults aged 18-65 years who were randomly selected from dwelling unit enumeration lists. The self-reported prevalence of current smoking was strikingly high among both men (48%) and women (41%), even among highly educated men (38%). The 21% of respondents without working telephones reported an even higher prevalence of current smoking (61%), indicating that national and state-based estimates which rely on telephone surveys may seriously underestimate the prevalence of smoking in poor urban communities. Among persons aged 35-64 years, the smoking attributable fractions for selected causes of death were larger in Harlem than in either New York City as a whole or the entire United States for both men and women. Tobacco consumption is likely to be one of several important mediators of the high numbers of premature deaths in Harlem.

The correction of lower lid malposition following lower lid blepharoplasty.

Lower eyelid malposition is the most common complication following lower eyelid blepharoplasty. This may take the form of a mild scleral show with the round eye syndrome or may progress to frank ectropion in some patients. When this problem occurs, it is imperative to soothe an already distressed patient by correcting the malposition by the most efficient method. A horizontal tightening of the lower lid at the lateral canthus can be helpful in many patients; however, in the more severe cases or in those in which the medial component is prominent, this procedure may not give the best correction. It is preferable to avoid using autogenous grafts in these patients because in most cases they will induce another incision line with potential deformity and, more important, are perceived by these sensitive patients as being more of an involved procedure. The preserved fasciae latae sling is an alternative procedure which is effective in the more severe cases of postblepharoplasty lower eyelid malposition, particularly in those cases in which the medial component of malposition is prominent.

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.

Browplasty and browpexy: an adjunct to blepharoplasty.

Surgical approaches to the eyelids and eyebrows have been refined by application of their anatomy and appreciation of their pathophysiology. Sexual variations in eyebrow appearance can be attributed in part to the eyebrow fat pad. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is flatter and at the level of the supraorbital rim. The eyebrow fat pad is more prominent in the male, producing a fuller appearance in the lateral brow area. Many women are concerned about the flatter, full lateral brow, which assumes a masculine quality. The authors describe a surgical technique that permits identification of the brow fat pad and then the ability to debulk the eyebrow (browplasty). In addition, the brow can be elevated by internal plication suture to physically elevate the eyebrow (browpexy). This procedure is designed to utilize an eyelid crease incision, and it reduces the indications for more involved procedures to eliminate brow ptosis, such as midforehead or coronal approaches.

Excess mortality in Harlem.

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.

Reconstruction of the anophthalmic socket: lower eyelid malposition and canthal tendon laxity.

There are a number of etiologies underlying the development of socket deformity with associated lower eyelid malposition, lateral canthal tendon laxity, and/or contraction of the inferior fornix. In addition to cosmetic considerations, each of these anatomic problems can interfere with comfortable wear and retention of a prosthesis. This chapter gives an overview of these problems and details our preferred surgical approaches to repair of these anatomic deformities. Specifically discussed are techniques for: mucous membrane and ear cartilage grafting to repair lower lid inner lamellar tissue shortage, reconstruction of the inferior fornix/cul-de-sac, direct lower eyelid lateral canthal resuspension, and resuspension using a periosteal flap or autogenous fascia lata from the iliotibial tract.

Malnutrition: an important determinant of fatal outcome in surgically treated pulmonary suppurative disease.

Eighty patients required surgical drainage of infections in the pleural space or lung during a four-year period (1984-1987). Thirty-nine patients had a history of heavy intravenous drug use and 28 of those not addicted to drugs were addicted to alcohol. Impaired immunity was believed to be present in 72 (90%) due to malnutrition (45 patients), acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (13), hepatic cirrhosis (1), diabetes (1), or multiple causes (12). Sixty-four patients had acute purulent empyema; 9, tuberculous empyema (often a mixed infection); 2, tuberculous pleural effusion with complications; 2, lung abscesses requiring open drainage; 2, chronic bronchopleural fistulae; and 1, empyema secondary to an esophageal perforation. Fifty-three (66%) were treated with tube thoracostomy only and 27 required additional procedures, including open drainage (19 patients), decortication (5), lung resection (2), chest wall resection (1), and parietal pericardiectomy (1). Overall mortality was high (30%); mortality had a strong correlation with malnutrition or immune deficiency. Very low serum albumin levels were common and were the most important single determinant of a fatal outcome: (table; see text) Other important determinants of mortality were: total lymphocytes less than 1000 (50% mortality); anergy to tests for delayed hypersensitivity (39% mortality); AIDS or AIDS-related complex (54% mortality). Analysis of the records of the 24 patients who died has led to the conclusion that despite the advanced disease present and the poor condition of most patients at least one third of the deaths could have been avoided if important errors in diagnosis and medical or surgical management could have been prevented.(ABSTRACT TRUNCATED AT 250 WORDS)

Mascara and eyelining tattoos: MRI artifacts.

Magnetic resonance imaging (MRI) is very useful in the evaluation of ocular and orbital disease. Heavy metal particles, used in the pigment base of mascara and eyelining tattoos, have a paramagnetic effect that causes alteration of the local magnetic field in adjacent tissues. These changes in normal signal result in distortion of the globes. In some cases, the distortion may mimic actual ocular disease such as a ciliary body melanoma or cyst.

Blepharochalasis.

Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.