Journal Article > ResearchSubscription Only
World J Surg. 2021 February 9; Volume 45 (Issue 5); 1400-1408.; DOI:10.1007/s00268-021-05972-1
Rahman A, Chao TE, Trelles M, Dominguez LB, Mupenda J, et al.
World J Surg. 2021 February 9; Volume 45 (Issue 5); 1400-1408.; DOI:10.1007/s00268-021-05972-1
BACKGROUND
Médecins Sans Frontières (MSF) provides surgical care in fragile states, which are more vulnerable to conflict. The primary objective of this study was to compare the indications for operative intervention in surgical projects in fragile states during periods of active conflict (CON) and non-conflict (NON-CON). In addition, risk factors for non-obstetric and obstetric operative mortality were identified.
METHODS
This was a retrospective analysis of MSF surgical projects in fragile states January 1, 2008–December 31, 2017. Variables considered in the analysis include age, gender, American Society of Anesthesiology physical status, emergency status, re-intervention status, indication for surgical intervention, and conflict/non-conflict time period.
RESULTS
There were 30 surgical projects in 13 fragile states with 87,968 surgical interventions in 68,667 patients. Obstetric needs were the most common indication for surgical intervention (n = 28,060, 31.9%) but were more common during NON-CON (n = 23,142, 35.7%) compared to CON periods (n = 4,918, 21.2%, p < 0.001). Trauma was more common during CON (42.0%) compared to NON-CON (23.0%) periods (p < 0.001). Non-obstetric operative mortality was similar during CON (0.2%) compared to NON-CON (0.2%, p = 0.920), but obstetric operative mortality was higher (0.5%) during CON compared to NON-CON (0.2%, p < 0.001) periods. Risk factors for obstetric and non-obstetric mortality included age ≥ 30 years, ASA greater than 1, and emergency intervention.
CONCLUSIONS
Humanitarian surgeons working in fragile states should be prepared to treat a range of surgical needs including trauma and obstetrics during conflict and non-conflict periods. The mortality in obstetric patients was higher during conflict periods, and further research to understand ways to protect this vulnerable group is needed.
Médecins Sans Frontières (MSF) provides surgical care in fragile states, which are more vulnerable to conflict. The primary objective of this study was to compare the indications for operative intervention in surgical projects in fragile states during periods of active conflict (CON) and non-conflict (NON-CON). In addition, risk factors for non-obstetric and obstetric operative mortality were identified.
METHODS
This was a retrospective analysis of MSF surgical projects in fragile states January 1, 2008–December 31, 2017. Variables considered in the analysis include age, gender, American Society of Anesthesiology physical status, emergency status, re-intervention status, indication for surgical intervention, and conflict/non-conflict time period.
RESULTS
There were 30 surgical projects in 13 fragile states with 87,968 surgical interventions in 68,667 patients. Obstetric needs were the most common indication for surgical intervention (n = 28,060, 31.9%) but were more common during NON-CON (n = 23,142, 35.7%) compared to CON periods (n = 4,918, 21.2%, p < 0.001). Trauma was more common during CON (42.0%) compared to NON-CON (23.0%) periods (p < 0.001). Non-obstetric operative mortality was similar during CON (0.2%) compared to NON-CON (0.2%, p = 0.920), but obstetric operative mortality was higher (0.5%) during CON compared to NON-CON (0.2%, p < 0.001) periods. Risk factors for obstetric and non-obstetric mortality included age ≥ 30 years, ASA greater than 1, and emergency intervention.
CONCLUSIONS
Humanitarian surgeons working in fragile states should be prepared to treat a range of surgical needs including trauma and obstetrics during conflict and non-conflict periods. The mortality in obstetric patients was higher during conflict periods, and further research to understand ways to protect this vulnerable group is needed.
Journal Article > ResearchAbstract
Int J STD AIDS. 2012 June 1; Volume 23 (Issue 6); DOI:10.1258/ijsa.2009.009328
Chu KM, Manzi M, Zuniga I, Biot M, Ford NP, et al.
Int J STD AIDS. 2012 June 1; Volume 23 (Issue 6); DOI:10.1258/ijsa.2009.009328
To describe the frequency, risk factors, and clinical signs and symptoms associated with hepatotoxicity (HT) in patients on nevirapine- or efavirenz-based antiretroviral therapy (ART), we conducted a retrospective cohort analysis of patients attending the ART clinic in Kibera, Kenya, from April 2003 to December 2006 and in Mavalane, Mozambique, from December 2002 to March 2007. Data were collected on 5832 HIV-positive individuals who had initiated nevirapine- or efavirenz-based ART. Median baseline CD4+ count was 125 cells/μL (interquartile range [IQR] 55-196). Over a median follow-up time of 426 (IQR 147-693) days, 124 (2.4%) patients developed HT. Forty-one (54.7%) of 75 patients with grade 3 HT compared with 21 (80.8%) of 26 with grade 4 had associated clinical signs or symptoms (P = 0.018). Four (5.7%) of 124 patients with HT died in the first six months compared with 271 (5.3%) of 5159 patients who did not develop HT (P = 0.315). The proportion of patients developing HT was low and HT was not associated with increased mortality. Clinical signs and symptoms identified 50% of grade 3 HT and most cases of grade 4 HT. This suggests that in settings where alanine aminotransferase measurement is not feasible, nevirapine- and efavirenz-based ART may be given safely without laboratory monitoring.
Journal Article > ResearchFull Text
PLOS One. 2010 February 17; Volume 5 (Issue 2); DOI:10.1371/journal.pone.0009183
Chu KM, Boulle AM, Ford NP, Goemaere E, Asselman V, et al.
PLOS One. 2010 February 17; Volume 5 (Issue 2); DOI:10.1371/journal.pone.0009183
BACKGROUND: The majority of antiretroviral treatment programmes in sub-Saharan Africa are scaling up antiretroviral treatment using a fixed dose first-line antiretroviral regimen containing stavudine, lamivudine, and nevirapine. One of the primary concerns with the use of this regimen is nevirapine-associated hepatotoxicity. METHODOLOGY/PRINCIPAL FINDINGS: Study participants were 1809 HIV-infected, antiretroviral naïve adults initiating nevirapine-based antiretroviral therapy between November 2002 and December 2006. The primary outcome was early hepatotoxicity. Secondary outcomes were associations with hepatotoxicity and mortality at six months. The cumulative proportion of early hepatotoxicity ranged from 1.0-2.0% giving an incidence-rate at 102 days of 3.6-7.6 per 100 person-years. Median time to hepatotoxicity was 32 (IQR 28-58) days. At 12 weeks, only 8% of patients had alanine aminotransferase monitoring at all the time-points recommended by national guidelines. No association was found between age, gender, baseline CD4 count, concurrent tuberculosis infection, prior participation in a prevention of mother-to-child-transmission program, or baseline weight and early hepatotoxicity. There was no association between early hepatotoxicity and mortality. CONCLUSIONS: The cumulative proportion of early hepatotoxicity in nevirapine based antiretroviral therapy was low in this resource-constrained setting. Hepatotoxicity was not associated with mortality. Frequent routine monitoring of alanine aminotransferase proved difficult to implement in this public sector primary care programme. Focused monitoring in the first month may be a more cost-effective and pragmatic option in settings with limited resources. Correlation with clinical signs and symptoms may allow future alanine aminotransferase testing to be dictated by clinical criteria.
Journal Article > ResearchFull Text
Archives of Surgery/JAMA Surgery. 2010 August 1; Volume 145 (Issue 8); DOI:10.1001/archsurg.2010.137
Chu KM, Ford NP, Trelles M
Archives of Surgery/JAMA Surgery. 2010 August 1; Volume 145 (Issue 8); DOI:10.1001/archsurg.2010.137
OBJECTIVE: To determine operative mortality in surgical programs from resource-limited settings. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. MAIN OUTCOME MEASURE: Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS: Between 2001 and 2008, 19,643 procedures were performed on 18,653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS: Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.
Journal Article > CommentaryFull Text
PLOS Med. 2009 May 19; Volume 6 (Issue 5); e1000078.; DOI:10.1371/journal.pmed.1000078
Chu KM, Rosseel P, Gielis P, Ford NP
PLOS Med. 2009 May 19; Volume 6 (Issue 5); e1000078.; DOI:10.1371/journal.pmed.1000078
SUMMARY POINTS:
•. Surgically treatable problems account for a significant proportion of disease burden in resource-limited settings, but are neglected due to lack of skilled professionals, adequate infrastructure and equipment, and the perception that surgical services are complex and expensive.
•. In the absence of trained surgeons, surgical tasks are often performed by non-specialist physicians and non-physician clinicians. While evaluations have proven the effectiveness of such task shifting, this is often done de facto, with little supervisory or training framework in place.
•. As efforts increase to scale up surgical care in the developing world, a number of important lessons from task shifting in the field of HIV/AIDS care could serve to support task shifting in surgery.
•. These include clearly defining the limits of task shifting, ensuring adequate training and supervision, providing adequate recognition and remuneration, developing simplified tools and guidelines, ensuring engagement with regulatory bodies, and mobilizing community health workers.
•. Surgically treatable problems account for a significant proportion of disease burden in resource-limited settings, but are neglected due to lack of skilled professionals, adequate infrastructure and equipment, and the perception that surgical services are complex and expensive.
•. In the absence of trained surgeons, surgical tasks are often performed by non-specialist physicians and non-physician clinicians. While evaluations have proven the effectiveness of such task shifting, this is often done de facto, with little supervisory or training framework in place.
•. As efforts increase to scale up surgical care in the developing world, a number of important lessons from task shifting in the field of HIV/AIDS care could serve to support task shifting in surgery.
•. These include clearly defining the limits of task shifting, ensuring adequate training and supervision, providing adequate recognition and remuneration, developing simplified tools and guidelines, ensuring engagement with regulatory bodies, and mobilizing community health workers.
Journal Article > CommentaryAbstract Only
World J Surg. 2009 August 12; Volume 34 (Issue 3); 411-414.; DOI:10.1007/s00268-009-0187-z
Chu KM, Rosseel P, Trelles M, Gielis P
World J Surg. 2009 August 12; Volume 34 (Issue 3); 411-414.; DOI:10.1007/s00268-009-0187-z
Médecins Sans Frontières (MSF) is a humanitarian organization that performs emergency and elective surgical services in both conflict and non-conflict settings in over 70 countries. In 2006 MSF surgeons departed on approximately 125 missions, and over 64,000 surgical interventions were carried out in some 20 countries worldwide. Historically, the majority of MSF surgical projects began in response to conflicts or natural disasters. During an emergency response, MSF has resources to set up major operating facilities within 48 h in remote areas. One of MSF strengths is its supply chain. Large pre-packaged surgical kits, veritable "operating theatres to go," can be readied in enormous crates and quickly loaded onto planes. In more stable contexts, MSF has also strengthened the delivery of surgical services within a country's public health system. The MSF surgeon is the generalist in the broadest sense and performs vascular, obstetrical, orthopaedic, and other specialized surgical procedures. The organization aims to provide surgical services only temporarily. When there is a decrease in acute needs a program will be closed, or more importantly, turned over to the Ministry of Health or another non-governmental organization. The long-term solution to alleviating the global burden of surgical disease lies in building up a domestic surgical workforce capable of responding to the major causes of surgery-related morbidity and mortality. However, given that even countries with the resources of the United States suffer from an insufficiency of surgeons, the need for international emergency organizations to provide surgical assistance during acute emergencies will remain for the foreseeable future.
Journal Article > CommentaryFull Text
PLOS Med. 2011 April 26; Volume 8 (Issue 4); e1001025.; DOI:10.1371/journal.pmed.1001025
Chu KM, Stokes C, Trelles M, Ford NP
PLOS Med. 2011 April 26; Volume 8 (Issue 4); e1001025.; DOI:10.1371/journal.pmed.1001025
Journal Article > CommentaryFull Text
Lancet. 2010 January 23; Volume 375 (Issue 9711); DOI:10.1016/S0140-6736(10)60107-9
Chu KM, Trelles M, Ford NP
Lancet. 2010 January 23; Volume 375 (Issue 9711); DOI:10.1016/S0140-6736(10)60107-9
Journal Article > ResearchFull Text
Int Health. 2009 September 1; Volume 1 (Issue 1); 97-101.; DOI:10.1016/j.inhe.2009.03.002
Caluwaerts C, Maendaenda R, Maldonado F, Biot M, Ford NP, et al.
Int Health. 2009 September 1; Volume 1 (Issue 1); 97-101.; DOI:10.1016/j.inhe.2009.03.002
Scale-up of antiretroviral therapy (ART) in sub-Saharan Africa is a major public health priority, but ensuring long-term adherence to treatment is a growing concern. The objectives of this retrospective study were to determine risk factors and true outcomes for individuals lost to follow-up in a routine HIV/AIDS care programme in Tete, Mozambique. Between May 2002 and August 2007, 2818 individuals were initiated on ART and 594 (21%) considered lost to follow-up were actively traced. Risk factors for being lost to follow-up were: age between 16 and 35 years [odds ratio (OR) = 1.4, P = 0.009]; CD4 count <50 cells/μl (OR = 1.7, P < 0.001); time on ART <3 months (OR = 3.6, P < 0.001); tuberculosis infection (OR = 2.5, P < 0.001); and Kaposi's sarcoma infection (OR = 5.9, P < 0.001). Sixty-four percent (380/594) of patients lost to follow-up could not be traced. Of the 214 (36%) that could be traced, 118 (55%) were dead, 43 (20%) were transferred out, 7 (3%) were misclassified and 46 (22%) were true defaulters. Active tracing should be conducted routinely to better understand the reasons for defaulting and to provide evidence for action. Early mortality may be reduced by enrolling patients in care as early as possible and providing optimal adherence counselling in the first months.
Journal Article > ResearchFull Text
Confl Health. 2010 April 14; Volume 4 (Issue 1); DOI:10.1186/1752-1505-4-6
Chu KM, Havet P, Ford NP, Trelles M
Confl Health. 2010 April 14; Volume 4 (Issue 1); DOI:10.1186/1752-1505-4-6
ABSTRACT: BACKGROUND: The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Medecins sans Frontieres in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. METHODS: We analysed data on all surgical interventions done at Masisi district hospital between September 2007 to December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. RESULTS: 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57%) of all surgical pathology and infections for another quarter (160, 14%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related. Male gender (adjusted odds ratio (AOR)=20.0, p<0.001), military status (AOR=4.1, p<0.001), and age less than 20 years (AOR=2.1, p<0.001) were associated with violence-related injury. Immediate peri-operative mortality was 0.2%. CONCLUSIONS: In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys to improve program planning and resource allocation and the effectiveness of the humanitarian response.