Evaluating the collection, comparability and findings of six global surgery indicators.

BACKGROUND: In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. METHODS: Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. RESULTS: Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916-2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. CONCLUSION: Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

Global health education in Swedish medical schools.

AIMS: Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students' perceived needs for such education. METHODS: Data on global health education were collected from all medical faculties in Sweden for the years 2000-2013. In addition, 76% (439/577) of all Swedish medical students in their final semester answered a structured questionnaire. RESULTS: Global health education is offered at four of Sweden's seven medical schools, and most medical students have had no global health education. Medical students in their final semester consider themselves to lack knowledge and skills in areas such as the global burden of disease (51%), social determinants of health (52%), culture and health (60%), climate and health (62%), health promotion and disease prevention (66%), strategies for equal access to health care (69%) and global health care systems (72%). A significant association was found between self-assessed competence and the amount of global health education received (p<0.001). A majority of Swedish medical students (83%) wished to have more global health education added to the curriculum. CONCLUSIONS: Most Swedish medical students have had no global health education as part of their medical school curriculum. Expanded education in global health is sought after by medical students and could strengthen the professional development of future medical doctors in a wide range of topics important for practitioners in the global world of the twenty-first century.

The global met need for emergency obstetric care: a systematic review.

BACKGROUND: Of the 287,000 maternal deaths every year, 99% happen in low- and middle-income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as 'Met need for EmOC'. OBJECTIVE: To estimate the global met need for EmOC and to examine the correlation between met need, maternal mortality ratio and other indicators. SEARCH STRATEGY: A systematic review was performed according to the PRISMA guidelines. Searches were made in PubMed, EMBASE and Google Scholar. SELECTION CRITERIA: Studies containing data on met need in EmOC were selected. DATA COLLECTION AND ANALYSIS: Analysis was performed with data extracted from 62 studies representing 51 countries. World Bank data were used for univariate and multiple linear regression. MAIN RESULTS: Global met need for EmOC was 45% (IQR: 28-57%), with significant disparity between low- (21% [12-31%]), middle- (32% [15-56%]), and high-income countries (99% [99-99%]), (P = 0.041). This corresponds to 11.4 million (8.8-14.8) untreated complications yearly and 951 million (645-1174 million) women without access to EmOC. We found an inverse correlation between met need and maternal mortality ratio (r = -0.42, P < 0.001). Met need was significantly correlated with the proportion of births attended by skilled birth attendants (ß = 0.53 [95% CI 0.41-0.65], P < 0.001). AUTHORS' CONCLUSIONS: The results suggest a considerable inadequacy in global met need for EmOC, with vast disparities between countries of different income levels. Met need is a powerful indicator of the response to maternal mortality and strategies to improve EmOC act in synergy with the expansion of skilled birth attendance.

Deaths among adult patients with hypopituitarism: hypocortisolism during acute stress, and de novo malignant brain tumors contribute to an increased mortality.

CONTEXT: Patients with hypopituitarism have an increased standardized mortality rate. The basis for this has not been fully clarified. OBJECTIVE: To investigate in detail the cause of death in a large cohort of patients with hypopituitarism subjected to long-term follow-up. DESIGN AND METHODS: All-cause and cause-specific mortality in 1286 Swedish patients with hypopituitarism prospectively monitored in KIMS (Pfizer International Metabolic Database) 1995-2009 were compared to general population data in the Swedish National Cause of Death Registry. In addition, events reported in KIMS, medical records, and postmortem reports were reviewed. MAIN OUTCOME MEASURES: Standardized mortality ratios (SMR) were calculated, with stratification for gender, attained age, and calendar year during follow-up. RESULTS: An excess mortality was found, 120 deaths vs 84.3 expected, SMR 1.42 (95% confidence interval: 1.18-1.70). Infections, brain cancer, and sudden death were associated with significantly increased SMRs (6.32, 9.40, and 4.10, respectively). Fifteen patients, all ACTH-deficient, died from infections. Eight of these patients were considered to be in a state of adrenal crisis in connection with death (medical reports and post-mortem examinations). Another 8 patients died from de novo malignant brain tumors, 6 of which had had a benign pituitary lesion at baseline. Six of these 8 subjects had received prior radiation therapy. CONCLUSION: Two important causes of excess mortality were identified: first, adrenal crisis in response to acute stress and intercurrent illness; second, increased risk of a late appearance of de novo malignant brain tumors in patients who previously received radiotherapy. Both of these causes may be in part preventable by changes in the management of pituitary disease.

Risk for severe hypoglycaemia with unawareness in GH-deficient patients during the insulin tolerance test.

OBJECTIVE: The insulin tolerance test (ITT) has been suggested as the gold standard for diagnosing GH deficiency (GHD). The ITT is, however, potentially hazardous. Glucose monitoring during the ITT varies between centres and there is surprisingly little information on the actual level of blood glucose nadir and the duration of hypoglycaemia in patients undergoing the ITT. The aim of the present study was to closely monitor the blood glucose level and to register the presence of symptoms and signs of hypoglycaemia during the ITT. DESIGN AND PATIENTS: Sixteen patients (seven women), aged 22-59 years were consecutively recruited for an ITT, and showed GHD (peak GH < 3 microg/l). RESULTS: In five (31%) of the patients unawareness of hypoglycaemia was recorded, the median nadir blood glucose level was 1.4 mmol/l (range 1.1-1.9) and the duration of blood glucose < 2.2 mmol/l was 25 min (range 20-33). The remaining 11 patients were symptomatic, and tiredness (n=6) and dizziness (n=3) were the most frequent symptoms. In these symptomatic patients the median nadir blood glucose level was 1.3 mmol/l (range 1.0-1.6) and the duration of blood glucose < 2.2 mmol/l was 25 min (range 15-30). CONCLUSIONS: In patients with GHD subjected to the ITT, symptoms of hypoglycaemia were scarce and a third showed unawareness. Close blood glucose monitoring is recommended at the ITT as low nadir blood glucose levels and long duration of hypoglycaemia may be present irrespective of symptoms of hypoglycaemia. Recommendations for intervention with intravenous glucose, at unacceptable low blood glucose levels or at prolonged hypoglycaemia, are warranted.

l-dopa-induced reversal in striatal glutamate following partial depletion of nigrostriatal dopamine with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine.

We have reported that 1 month following acute (20mg/kg x 4) or subchronic (30 mg/kg/day x 7d) administration of the neurotoxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, there is an increase or decrease, respectively, in the extracellular level of striatal glutamate as determined by in vivo microdialysis [Robinson S, Freeman P, Moore C, Touchon JC, Krentz L, Meshul CK (2003) Acute and subchronic MPTP administration differentially affects striatal glutamate synaptic function. Exp Neurol 180:73-86]. The goal of this study was to determine the effects of treatment with l-dopa (15 mg/kg) for 21 days on striatal glutamate starting on day 8 after the first dose of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine was administered to mice. Following acute administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, the increase in extracellular striatal glutamate due to lesion of the nigrostriatal pathway was completely reversed to a level below that found in the vehicle-treated group after l-dopa treatment. Subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine treatment resulted in a decrease in striatal extracellular glutamate that was reversed to the level close to that observed in the vehicle-treated group. There was no change in the density of nerve terminal glutamate immunolabeling associated with the synaptic vesicle pool, suggesting that the alterations in extracellular glutamate most likely originated from the calcium-independent pool. There was a similar decrease in the relative density of tyrosine hydroxylase immunolabeling, a marker for dopamine terminals, within the dorsolateral striatum in both the acute and subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated groups that had been administered l-dopa. There was a decrease in the relative density of immunolabeling within the dorsolateral striatum for the glutamate transporter, GLT-1, following acute 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine treatment in the groups administered either vehicle or l-dopa. There was no change in GLT-1 immunolabeling following subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. The results demonstrate that the reversal in the extracellular level of striatal glutamate following l-dopa treatment in both the acute and subchronic 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated groups is not due to changes in either striatal dopamine nerve terminals or in the density of the glutamate transporter, GLT-1.