Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care

Background

Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.

Methods

A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r _w) and linear regression models.

Results

A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5–62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8–111.0), compared to 9.4 (IQR 3.4–13.4) for the United States and 5.5 (IQR 4.4–10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = ?63.2; 95% CI ?119.6 to ?6.9; P = 0.036).

Conclusions

The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.

     

Comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures

Fracture mapping has been used in the understanding of injury patterns in different bones. To our knowledge, there are no applications of this technique using three‐dimensional (3D) morphologic fracture characteristics. Previously, scapula fractures were mapped by transferring information from 3D computed tomography to a two‐dimensional (2D) template. Cole et al. determined that 3D Computerized Tomography (CT) scans were more reliable compared to plain radiographs in terms of scapular angulation, translation, and glenopolar angle measurements. Thus, we hypothesized that if there is a difference between fracture lines drawn in 3D and in 2D, then the 3D mapping would yield more accurate fracture patterns. We completed a retrospective, comparative study (evidence level III) utilizing CT imaging from a single center scapular registry. We studied ten patients with scapula fractures in whom bilateral CT scans were obtained. Fractures were mapped both two and three‐dimensionally, and we measured deviations between the fracture lines that were drawn with each approach. The measured deviations ranged from 10.4 mm to 28.0 mm when comparing 2D versus 3D techniques, with the mean deviation being 4.0 mm and 10.4 mm, respectively. Half of the 2D renderings possessed hidden fracture lines that were later revealed on 3D imaging. Three‐dimensional renderings were more accurate when compared to 2D fracture mapping methods. This more accurate technique will allow for better understanding of 3D morphology and provide a basis for future fracture mapping in any bone. Accurate mapping is important because surgical approach, reduction, fixation, and implant design and selection are based on fracture patterns. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:265–271, 2018.     

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials

Adjuvant treatments including Betadine, Dakin's solution (sodium hypochlorite), or hydrogen peroxide (H₂O₂) have been attempted to eradicate prosthetic joint infection caused by biofilm or intracellular bacteria. The purpose of this study was to evaluate the in vitro abilities of chemical adjuvants to decrease Staphylococcus aureus (S. aureus) biofilm presence on orthopaedic implant grade materials, including titanium, stainless steel, and cobalt chrome. S. aureus biofilms were grown for 48 h and evaluated for baseline colony forming units/centimeter squared (CFU/cm²) and compared to treatments with Betadine, Dakin's solution, H₂O₂, or 1% chlorine dioxide (ClO₂). Control discs (n = 18) across all metals had an average of 4.2 × 10⁷ CFU/cm². All treatments had statistically significant reductions in CFU/cm² when compared to respective control discs (p < 0.05). For all metals combined, the most efficacious treatments were Betadine and H₂O₂, with an average 98% and 97% CFU/cm² reduction, respectively. There were no significant differences between reductions seen with Betadine and H₂O₂, but both groups had statistically greater reductions than Dakin's solution and ClO₂. There was no change in antibiotic resistance patterns after treatment. Analysis of S. aureus biofilms demonstrated a statistically significant reduction in biofilm after a five‐minute treatment with the modalities, with an average two log reduction in CFU/cm². Statement of clinical significance: While statistically significant reductions in CFU/cm² were accomplished with chemical adjuvant treatments, the overall concentration of bacteria never fell below 10⁵ CFU/cm², leading to questionable clinical significance. Further techniques to eradicate biofilm should be investigated. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1599–1604, 2018.

     

Management of acute intra-abdominal hemorrhage in ruptured hepatoblastoma with transarterial embolization using calibrated gelfoam particles

This brief report aims to evaluate the treatment outcome of transarterial embolization in ruptured hepatoblastoma complicated with acute intra-abdominal hemorrhage. Three children (mean age 6 years) with high-risk hepatoblastoma presented with rupture and acute intra-abdominal hemorrhage. In addition to aggressive fluid resuscitation and blood product support, super-selective embolization of the arteries with active bleeding or pseudoaneurysm was performed using calibrated gelfoam particles, with a technical success rate of 100%. Hemodynamic status and hemoglobin level were normalized in all patients within 2 days postembolization. The 30-day survival rate was 100%. No major complication was detected apart from mild elevation of alanine transaminase.