DGHI

Background: Barriers to surgical care in low-and middle-income countries have basis in theoretical frameworks, but are often left undefined and understudied. Based on the Access Evaluation Framework and Healthcare Barrier Model, this study implemented two consumer decision tools and a qualitative interview to elucidate significant barriers to seeking surgical care in Uganda. Methods: Participants were recruited from a convenience sample within the surgical wards of one national referral hospital and one regional referral hospital in Uganda. Individuals selected for the study answered a brief questionnaire and a ranking and rating exercise followed by an in-depth semi-structured interview. The questionnaire evaluated demographic, economic, transportation, and care-seeking characteristics, while the ranking and rating exercises assessed potential barriers to surgical care. Descriptive statistics were used to assess characteristics of the sample. Ranking and rating medians were compared between the two exercises for each barrier. Results: Among the 214 participants, cost of surgery, distance to hospital, and transportation to hospital were identified as the most significant barriers to care. Language barrier, no control over decision making, and no caretaker available at the hospital were identified as the least significant barriers to care. Mulago National Referral Hospital had significantly greater costs and transportation times indicating larger scale v barriers to care than Jinja Regional Referral Hospital even though top barriers were similar. Conclusions: Both the ranking and rating exercises and interviews indicated that cost was the most significant barrier to surgical care among care-seekers in Uganda. Transportation to the hospital and distance from the hospital remain large barriers that need to be considered as well. These complementary analysis tools provide evidence that future policies and research need to consider mitigating cost, distance, and transportation issues for patients that need a surgical intervention. Next steps in determining more granular level differences between barriers will help understand how best to address these issues. vi Dedication This work is dedicated to all those who pushed me to be the individual I am today, throughout my time as a student and as I look towards my career. To my parents, who have sacrificed much to afford me the opportunities I have had thus far in life. To Jeff and Eric for unconditional support, encouragement, and humor. And to Amy for constantly being a reminder of why I am pursuing my dreams. I further dedicate this thesis to all those fighting for their lives within the hospitals of Uganda, those without the ability to receive the care they need, and the selfless healthcare workers who work day in and day out to provide services to many, often at their own expense. This work is for a better future for you all.

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia. Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals. Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up. Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure. Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.

Background: Working in partnership with the Cambodian Ministry of Health, the Safe Surgery 2020 initiative (SS2020) supports the prioritization of surgery and mobilization of resources to target limited workforce capacity. An evaluation study was conducted to assess the impact of SS2020 on intervention hospitals in Cambodia. Objective: To understand the impact of the SS2020 program on intervention hospitals in Cambodia by assessing the changes in key surgical performance indicators before and after the intervention, identifying key barriers and facilitators to adoption of learnings, and discovering lessons on the uptake and diffusion of this initiative in Cambodia and other similar contexts. Methods: This study is a convergent mixed-methods evaluation of a one-year multicomponent SS2020 intervention. Surgical observations were conducted in 8 intervention hospitals at baseline and endline to evaluate pre and post adherence to 20 safety, teamwork, and communication items. Fifteen focus groups were conducted in all intervention sites at endline to assess key facilitators and barriers to positive impact. Results: There was significant improvement in 19 of 20 indicators assessed during surgical observations. Among the highest performing indicators were safety items; among the lowest were communication items. Participants self-reported improved knowledge and positive behavior change after the intervention. Institutional change and direct patient impact were not widely reported. Most participants had favorable views of the mentorship model and were eager for the program to continue implementation. Conclusions: The results provide evidence that change in surgical ecosystems can be achieved on a short timeline with limited resources. The hub-and-spoke mentorship model can be successful in improving knowledge and changing behavior in surgical safety. Workforce development is important to improving surgical systems, but greater financial and human resources are needed. Ministry support in adopting, leading, and scaling is crucial to the continued success of safe surgery interventions in Cambodia.

Background: Chronic exposure to arsenic through drinking water has the potential to cause adverse pregnancy outcomes, although the association has not been demonstrated conclusively. This crosssectional study assessed the association between arsenic in drinking water and spontaneous abortion, stillbirth, and neonatal death. Methods: In this cross-sectional study, 533 women were interviewed. Information on sociodemographic characteristics, drinking water use, and adverse pregnancy outcomes was obtained through a structured pretested interviewer-administered questionnaire. The respondents reported use of a total of 223 tube wells; for 208 wells, water samples were measured using an ultraviolet/visible spectrophotometry method, whereas 15 were measured by flow-injection hydride generation atomic absorption spectrometry (FIHG-AAS). Results: Excess risks for spontaneous abortion and stillbirth were observed among the participants chronically exposed to higher concentrations of arsenic in drinking water after adjusting for participant's height, history of hypertension and diabetes, and (for neonatal death only) age at first pregnancy. Comparing exposure to arsenic concentration of greater than 50 g/L with 50 g/L or less, the odds ratios were 2.5 (95% confidence interval ϭ 1.5-4.3) for spontaneous abortion, 2.5 (1.3-4.9) for stillbirth, and 1.8 (0.9 -3.6) for neonatal death. Conclusions: These study findings suggest that chronic arsenic exposure may increase the risk of fetal and infant death.

The role of nutritional factors in arsenic metabolism and toxicity is not clear. Provision of certain low protein diets resulted in decreased excretion of DMA and increased tissue retention of arsenic in experimental studies. This paper reports a prevalence comparison study conducted in Bangladesh to assess the nutritional status among the chronic arsenic exposed and unexposed population. 138 exposed individuals diagnosed as arsenicosis patients were selected from three known arsenic endemic villages of Bangladesh and age, sex matched 144 unexposed subjects were randomly selected from three arsenic free villages. The mean arsenic concentration in drinking water for the exposed and unexposed population was 641.15 and 13.5 mg L 71 respectively. Body Mass Index was found to be lower than 18.5, the cut off point for malnutrition, in 57 (41.31%) out of 138 exposed arsenicosis cases and 31 (21.53%) out of 144 unexposed individuals. The crude prevalence ratio (or risk) was 1.92 (95% CI = 1.33 -2.78) for poor nutritional status among the arsenicosis cases compared to the unexposed population. The findings of this study add to the evidence that poor nutritional status may increase an individual's susceptibility to chronic arsenic toxicity, or alternatively that arsenicosis may contribute to poor nutritional status.

Serotherapy of B-cell neoplasms with anti-B4-blocked ricin: a phase I http://bloodjournal.hematologylibrary.org/site/misc/rights.xhtml#repub_requests Information about reproducing this article in parts or in its entirety may be found online at:

Objectives. This study sought to determine whether a moderate intensity supervised exercise training program, performed immediately after an uncomplicated acute myocardial infarction, improves recovery in cardiac autonomic function compared with standard advice about activity at home.