The American College of Surgeons as an advocate for global surgery awareness.

The American College of Surgeons (ACS), founded in 1913, is the one of the oldest surgical professional organizations in the United States. Originally founded to foster surgical professional excellence and collaboration among surgeons in North America, the ACS has now expanded to over 80,000 members worldwide with programs delivering a rich portfolio of professional services in the domains of surgical education, clinical surgery and global surgery, surgical quality and leadership, surgical research, member services. ACS international programs initially focused on international professional exchange and hosting of young surgeons from around the world in US based surgical centers to develop scholarly and clinical collaborations. Over the last 20 years, with the founding of the ACS-Operation Giving Back (OGB) Program, the ACS has broadened its international perspective to support surgical care in emerging nations and to develop collaborative programs with host institutions in emerging nations to support surgical care capacity growth through on site partnerships, and educational and policy initiatives. To that end, in recent years, OGB has developed global surgical programs in the COSECSA region of sub-Saharan Africa creating opportunities to participate in Global Surgical Training Hubs. After developing a pilot hub project in Hawassa, Ethiopia, OGB is now in the process of scaling up two additional sites. In this manuscript, we will describe ACS's rich history of activities promoting international surgical collaboration and scholarship and discuss the process of creating the global surgical training hub model in Hawassa.

TB-related catastrophic costs in Ethiopia.

OBJECTIVES: To measure the progress towards reducing TB-related catastrophic costs in 19 zones of Amhara, Oromia, SNNP (Southern Nations and Nationalities, and Peoples) and Sidama Regions of Ethiopia. METHODS: A baseline survey was conducted in randomly selected health facilities from all districts within the 19 zones from November 2020 to February 2021. Interventions targeting the major drivers of catastrophic costs identified in the baseline survey, such as installation of 126 GeneXpert and 13 Truenat machines, securing connectivity of 372 GeneXpert, establishing alternative specimen referral systems, and capacity-building of health workers, were implemented. A follow-up survey was conducted from October to December 2022. The WHO generic tool was used to collect data based on probability proportional to size. Data were entered into STATA software, and the proportion of catastrophic costs was calculated and compared between the two surveys. RESULTS: A total of 433 and 397 patients participated in the baseline and follow-up surveys, respectively. The proportion of catastrophic costs reduced from 64.7% to 43.8% (P < 0.0001). The share of direct non-medical costs decreased from 76.2% to 19.2%, while medical and indirect costs increased from 11.6% and 12.3% to 30.4% and 52.4 %. CONCLUSION: The proportion of households facing TB-related catastrophic costs has significantly reduced over the 2-year period. However, it remains unacceptably high and varies among regions. Further reducing the catastrophic costs requires multisectoral response, reviewing the TB service exemption policy, further decentralisation and improving the quality of TB services.

OBJECTIFS: Mesurer les progrès accomplis dans la réduction des coûts catastrophiques liés à la TB dans 19 zones des régions d'Amhara, d'Oromia, de SNNP (Région des nations, nationalités et peuples du Sud) et de Sidama en Éthiopie. MÉTHODES: Une enquête de base a été menée dans des établissements de santé sélectionnés au hasard dans tous les districts des 19 zones de novembre 2020 à février 2021. Des interventions ciblant les principaux facteurs de coûts catastrophiques identifiés dans l'enquête de référence, telles que l'installation de 126 machines GeneXpert et 13 Truenat, la sécurisation de la connectivité de 372 GeneXpert, la mise en place de systèmes alternatifs d'orientation des échantillons et le renforcement des capacités des agents de santé, ont été mises en œuvre. Une enquête de suivi a été menée d'octobre à décembre 2022. L'outil générique de l'OMS a été utilisé pour recueillir des données fondées sur une probabilité proportionnelle à la taille. Les données ont été saisies dans le logiciel STATA, et la proportion des coûts catastrophiques a été calculée et comparée entre les deux enquêtes. RÉSULTATS: Au total, 433 et 397 patients ont participé respectivement à l'enquête de base et à l'enquête de suivi. La proportion des coûts catastrophiques est passée de 64,7% à 43,8% (P < 0,0001). La part des coûts non médicaux directs a diminué, passant de 76,2% à 19,2%, tandis que les coûts médicaux et indirects sont passés de 11,6% et 12,3% à 30,4% et 52,4%. CONCLUSION: La proportion de ménages confrontés à des coûts catastrophiques liés à la tuberculose a considérablement diminué au cours de la période de 2 ans. Cependant, il reste inacceptable et varie selon les régions. Pour réduire davantage les coûts catastrophiques, il faut une réponse multisectorielle, une révision de la politique d'exemption des services de lutte contre la TB, une décentralisation plus poussée et une amélioration de la qualité des services de lutte contre la TB.

Outcomes of WHO-conforming, longer, all-oral multidrug-resistant TB regimens and analysis implications.

BACKGROUND: Evidence of the effectiveness of the WHO-recommended design of longer individualized regimens for multidrug- or rifampicin-resistant TB (MDR/RR-TB) is limited.OBJECTIVES: To report end-of-treatment outcomes for MDR/RR-TB patients from a 2015-2018 multi-country cohort that received a regimen consistent with current 2022 WHO updated recommendations and describe the complexities of comparing regimens.METHODS: We analyzed a subset of participants from the endTB Observational Study who initiated a longer MDR/RR-TB regimen that was consistent with subsequent 2022 WHO guidance on regimen design for longer treatments. We excluded individuals who received an injectable agent or who received fewer than four likely effective drugs.RESULTS: Of the 759 participants analyzed, 607 (80.0%, 95% CI 77.0-82.7) experienced successful end-of-treatment outcomes. The frequency of success was high across groups, whether stratified on number of Group A drugs or fluoroquinolone resistance, and ranged from 72.1% to 90.0%. Regimens were highly variable regarding composition and the duration of individual drugs.CONCLUSIONS: Longer, all-oral, individualized regimens that were consistent with 2022 WHO guidance on regimen design had high frequencies of treatment success. Heterogeneous regimen compositions and drug durations precluded meaningful comparisons. Future research should examine which combinations of drugs maximize safety/tolerability and effectiveness.

Technical note and results in the management of anatomical variants of renal vascularisation during endovascular aneurysm repair.

INTRODUCTION: The revascularisation of large (>3 mm) renal arteries emerging from the proximal sealing zone or off the aneurismal wall can be challenging during endovascular aortic aneurysm repair. In this article, we describe various endovascular techniques using custom-made endografts to treat these complex variant anatomies. CASES: Nine patients deemed unfit for open repair with unusual renal vascularisation associated with aortic aneurysms were treated by endovascular means. After three-dimensional (3D) reconstructions on a dedicated workstation, custom-made devices were designed and manufactured. The revascularisation of multiple renal arteries and aberrant origins of renal arteries, associated or not with pelvic kidney or horseshoe kidney, was managed using fenestrated and branched endografts. RESULTS: All target vessels were patent on computed tomography (CT) scan and contrast-enhanced ultrasound evaluation before discharge as well as on the 6-month follow-up. One patient presented a decrease of postoperative glomerular filtration rate over 30% but did not require dialysis. No sac enlargement was depicted, and no reintervention was performed during follow-up. Three type 2 endoleaks were diagnosed. CONCLUSION: Endovascular treatment with fenestrated and branched endografts should be considered in challenging renal artery anatomies in patients unfit for open repair.

Women's utilisation of prevention of mother-to-child transmission of human immunodeficiency virus services in Addis Ababa, Ethiopia.

BACKGROUND: Human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) can be prevented when HIV-positive pregnant women use effective prevention of mother-to-child transmission (PMTCT) of HIV services. Approximately 50% of HIV-positive pregnant women used free PMTCT services in Ethiopia. AIM: This study attempted to identify factors influencing women's utilisation of PMTCT services. Addressing such factors could enable more Ethiopian women to use PMTCT services. The study investigated whether women's utilisation of services was affected by socio-demographic issues, their partners' known HIV status, disclosure of their HIV-positive status, stigma and discrimination, and satisfaction with services. SETTING: Prenatal clinics in Addis Ababa, Ethiopia. METHODS: A quantitative, cross-sectional study design was used and 384 questionnaires were completed by women who used PMTCT services in Addis Ababa. RESULTS: No socio-demographic characteristic prevented women's utilisation of PMTCT services, nor did stigma, discrimination or disclosure of their HIV-positive status. Most respondents' partners with unknown HIV status did not know that the respondents used PMTCT services. Most women were satisfied with the PMTCT services. CONCLUSIONS: Prevention of mother-to-child transmission services should remain accessible to all HIV-positive women in Ethiopia. Concurrent HIV partner testing should be encouraged with appropriate counselling. HIV-positive pregnant women should be encouraged to disclose their status to their partners so that they need not use PMTCT services secretly. Patients' high levels of satisfaction with PMTCT services are a good indicator for rolling out PMTCT initiatives at other facilities. Future research should focus on HIV-positive pregnant women who do not use PMTCT services.

Owner reported diseases of working equids in central Ethiopia.

REASONS FOR PERFORMING STUDY: Working horses, donkeys and mules suffer from numerous diseases and clinical problems. However, there is little information on what owners perceive as important health concerns in their working animals. OBJECTIVES: To identify and prioritise with owners the diseases and other health concerns in working equids in central Ethiopia using participatory methodologies. STUDY DESIGN: Participatory situation analysis (PSA). METHODS: The study was conducted with carthorse- and donkey-owners in 16 sites in central Ethiopia. Multiple participatory methodologies were utilised, including ranking, matrices and focus group discussions. Owners' perceptions on frequency, importance, morbidity and mortality of volunteered diseases and the clinical signs that owners attributed to each disease were obtained; information regarding the impact of these diseases and health concerns was also sought. RESULTS: A total of 40 separate disease and health problems were volunteered by carthorse- and donkey-owners. Horse-owners volunteered a musculoskeletal syndrome (with the local name 'bird', clinical signs suggest possible disease pathologies including equine exertional rhabdomyolysis), colic and epizootic lymphangitis most frequently, whereas donkey-owners volunteered sarcoids, nasal discharge and wounds to occur most frequently. One problem (coughing) was volunteered frequently by both horse- and donkey-owners. Owners demonstrated knowledge of differing manifestations and severity of these problems, which resulted in differing impacts on the working ability of the animal. CONCLUSIONS: Although many of the diseases and clinical signs had been previously reported, this study also identified some previously unreported priorities such as rabies in donkeys, an unidentified musculoskeletal syndrome in horses and respiratory signs in both horses and donkeys. The information gathered during this participatory study with owners may be used to inform future veterinary and educational programme interventions, as well as identify future research priorities.

An assessment of the outcomes of prevention of mother-to-child transmission of HIV services in Addis Ababa, Ethiopia.

BACKGROUND: This article assessed maternal and neonatal outcomes amongst users of prevention of mother-to-child transmission (PMTCT) of HIV services in Addis Ababa, Ethiopia. OBJECTIVES: The study aimed to assess the health outcomes (antiretroviral prophylaxis versus antiretroviral treatment, CD4 counts, World Health Organization (WHO) stages of illness, other illnesses) of women who had used these services, as well as the HIV status of their babies and the infant feeding method adopted. METHODS: A quantitative, cross sectional, retrospective cohort design was used. Document reviews were conducted with a sample of 384 mother-infant pairs (out of a population of 796) who had used PMTCT services. RESULTS: All respondents were using prophylactic antiretrovirals or antiretroviral therapy, but some were on the wrong treatment based on their CD4 counts. The CD4 counts increased four times more for women on antiretroviral treatment than for those on prophylactic antiretrovirals. The WHO's stages of HIV illness did not improve but deteriorated in some cases, and 52 other illnesses were recorded. Out of the 384 infants, 6.0% (n = 23) were HIV-positive. Most respondents opted for exclusive breast feeding but some used mixed feeding during the first six months of their infants' lives, despite having received health education related to infant feeding options. CONCLUSION: The respondents' improved CD4 counts were inadequate to improve their World Health Organization stages of HIV illness. Some babies received mixed feeding during the first six months of their lives and 6% of the babies were HIV-positive despite their mothers' utilisation of PMTCT services.

Clamp and sew techniques in thoracoabdominal aortic surgery using naloxone and CSF drainage.

Surgical repair of thoracoabdominal (TAA) and thoracic aneurysm is challenging, with the potentials for high morbidity and mortality. There is no standardized operative approach. Operative management of TAA consists of simple clamp-and-sew techniques with adjuncts, cerebrospinal fluid (CSF) drainage, naloxone administration, and intraoperative hypothermia, to protect the spinal cord. The use of CSF drainage and naloxone administration has reduced paraplegia to 3.4%, compared with 21% when none of these adjunctive spinal cord measures were used. The authors discuss their operative strategy, surgical technique, and results at the University of Wisconsin Hospital and Clinics.

A community-based participatory study investigating the epidemiology and effects of rabies to livestock owners in rural Ethiopia.

A participatory study was carried out in the Oromia region of Ethiopia to ascertain the principal epidemiological features of rabies and its impact on livestock owners. Due to the variation in topography (and therefore livestock and human populations within the study area) villages from both high (>1500 m) and lowland areas were included. Local development agents who had no knowledge of the study's purpose recruited a total of one hundred and ninety six participants from eleven lowland and ten highland villages. A facilitator trained in animal health and participatory techniques conducted the interviews with groups of up to eleven participants. Methods used included ranking, scoring, proportion piling, seasonality calendars and open discussions to investigate a set of questions pre determined from a pilot study. The relative importance of rabies to other zoonoses, temporal distributions of the disease, the species affected, current methods of control within affected species and consequences of their loss were all explored. Data was compared between high and lowland areas and previously published studies. The study found that rabies was considered the zoonosis of greatest risk to public health in both areas. It reportedly occurred with higher frequency in highland areas and subsequently affected more livestock in these parts. Two distinct temporal patterns within the areas were described and participants provided reasons of biological plausibility for the occurrence. Livestock were found to contribute as a higher proportion of all species affected than previously shown in published material. This is likely to be due to the low level of reporting of affected animals to the available veterinary services, from where comparative data originated. The death of infected livestock species was found to have numerous social and economic implications and the ramifications of this are made greater by the perception that the highest incidence of clinical disease being in areas of greatest livestock density. The underestimation of the burden of disease by central bodies is likely to influence the economic rationale behind effective rabies control in the future.

A cluster-randomised controlled trial to compare the effectiveness of different knowledge-transfer interventions for rural working equid users in Ethiopia.

There have been few studies evaluating the efficacy of knowledge-transfer methods for livestock owners in developing countries, and to the authors' knowledge no published work is available that evaluates the effect of knowledge-transfer interventions on the education of working equid users. A cluster-randomised controlled trial (c-RCT) was used to evaluate and compare the effectiveness of three knowledge-transfer interventions on knowledge-change about equid health amongst rural Ethiopian working equid users. Groups were exposed to either; an audio programme, a village meeting or a diagrammatic handout, all of which addressed identical learning objectives, and were compared to a control group which received no intervention. Thirty-two villages were randomly selected and interventions randomly assigned. All participants in a village received the same intervention. Knowledge levels were assessed by questionnaire administration. Data analysis included comparison of baseline data between intervention groups followed by multilevel linear regression models (allowing for clustering of individuals within village) to evaluate the change in knowledge between the different knowledge-transfer interventions. A total of 516 randomly selected participants completed the pre-intervention questionnaire, 504 of whom undertook the post-dissemination questionnaire, a follow up response rate of 98%. All interventions significantly improved the overall 'change in knowledge' score on the questionnaire compared to the control, with the diagrammatic handout (coefficient (coef) 9.5, S.E.=0.6) and the village meeting (coef 9.7, S.E.=0.6) having a significantly greater impact than the audio programme (coef 4.8, S.E.=0.6). Covariates that were different at baseline, and which were also significant in the final model, were age and pre-intervention score. Although they had a minimal effect on the intervention coefficients there was a significant interaction between age and intervention. This study should aid the design of education materials for adult learning for working equid users and other groups in developing countries.

High-resolution, time-resolved MRA provides superior definition of lower-extremity arterial segments compared to 2D time-of-flight imaging.

PURPOSE: To evaluate a novel time-resolved contrast-enhanced (CE) projection reconstruction (PR) magnetic resonance angiography (MRA) method for identifying potential bypass graft target vessels in patients with Class II-IV peripheral vascular disease. MATERIALS AND METHODS: Twenty patients (M:F = 15:5, mean age = 58 years, range = 48-83 years), were recruited from routine MRA referrals. All imaging was performed on a 1.5 T MRI system with fast gradients (Signa LX; GE Healthcare, Waukesha, WI). Images were acquired with a novel technique that combined undersampled PR with a time-resolved acquisition to yield an MRA method with high temporal and spatial resolution. The method is called PR hyper time-resolved imaging of contrast kinetics (PR-hyperTRICKS). Quantitative and qualitative analyses were used to compare two-dimensional (2D) time-of-flight (TOF) and PR-hyperTRICKS in 13 arterial segments per lower extremity. Statistical analysis was performed with the Wilcoxon signed-rank test. RESULTS: Fifteen percent (77/517) of the vessels were scored as missing or nondiagnostic with 2D TOF, but were scored as diagnostic with PR-hyperTRICKS. Image quality was superior with PR-hyperTRICKS vs. 2D TOF (on a four-point scale, mean rank = 3.3 +/- 1.2 vs. 2.9 +/- 1.2, P < 0.0001). PR-hyperTRICKS produced images with high contrast-to-noise ratios (CNR) and high spatial and temporal resolution. 2D TOF images were of inferior quality due to moderate spatial resolution, inferior CNR, greater flow-related artifacts, and absence of temporal resolution. CONCLUSION: PR-hyperTRICKS provides superior preoperative assessment of lower limb ischemia compared to 2D TOF.

Minimal incision aortic surgery.

PURPOSE: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). METHOD: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. RESULTS: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. CONCLUSIONS: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.