Surgical Service Utilization and In-Patient Satisfaction in Surgical Service.

BACKGROUND: The patient satisfaction study is an important and commonly used valid indicator for service quality improvement in healthcare institutions. The aim of this study was to assess the service utilization and patient satisfaction in patients admitted under surgical service in Bir Hospital. METHODS: A prospective cross sectional analytical study was conducted in Bir Hospital, National Academy of Medical Sciences from February 2021 till June 2023. The patient satisfaction data was collected using the SAPS scale after obtaining ethical clearance from the Institutional Review Board. Data were entered and analyzed in Statistical Package for the Social Sciences version 20.0. RESULTS: There were 152 patients included in the study categorized into conservative treatment group, elective surgery group and emergency surgery group. 32.9%(50) patients were "very satisfied", 62.5%(95) patients were "satisfied", 2.6%(4) were "neither satisfied nor dissatisfied" and 2%(3) were "dissatisfied" with the effect of their treatment/care. The mean satisfaction score in conservative treatment group was 22.13 ±2.53 as compared to the mean satisfaction in elective surgery group which was 21.11± 2.55 (P=0.036) and the mean satisfaction score in emergency surgery group which was 21.66 ±2.68 (P=0.64). CONCLUSIONS: The mean score and proportion of patient satisfaction regarding service utilization in patients admitted under surgical service were high with satisfaction score higher in emergency surgery group among the operative groups in Bir Hospital, National Academy of Medical Sciences.

Academic Global Surgery: Creating Opportunities, Equity, and Diversity.

A workforce trained in the development and delivery of equitable surgical care is critical in reducing the global burden of surgical disease. Academic global surgery aims to address the present inequities through collaborative partnerships that foster research, education, advocacy and training to support and increase the surgical capacity in settings with limited resources. Barriers include a deficiency of resources, personnel, equipment, and funding, a lack of communication, and geographical challenges. Multi-level partnerships remain fundamental; these types of partnerships include a wide range of trainees, professionals, institutions, and nations, yet care must be taken to avoid falling into the trap of surgical "voluntourism" and undermining the expertise and practice of long-standing frontline providers. Academic global surgery has the benefit of developing a community of surgeons who possess the tools needed to collaborate on individual, institutional, and international levels to address inequities in surgery that are spread variously across the globe. However, challenges for surgeons pursuing a career in global surgery include balancing clinical responsibilities while integrating global surgery as a career during training. This is due in part to the lack of mentorship, research time, grant funding, support to attend conferences, and a limitation of resources, all of which are significantly more pronounced for surgeons from low-resource countries.

Relationship Between Gender, Training Level and Goal Orientation Achievement Motivation: Implications for Learners and Faculty.

PURPOSE: Achievement goal orientation (GO) theory describes Mastery (M), one's intrinsic drive for competency for the sake of competency, and performance approach (PAP), a drive for competency by displaying competency, which are both adaptive. In learners motivated by performance avoid (PAV), showing competency by avoiding appearing incompetent dominates (maladaptive). The aim of this study was to determine differences in GO by gender and training (PGY) level. METHODS: A prospective, multi-institutional cohort of general surgery trainees participated in a cross-sectional study (2020-2021). Participants completed a 10-item instrument (the Goal Orientation in Surgical Trainees, GO-ST) measured on a 5-pointLikert scale (1 = never,3 = weekly,5 = daily). Student's t-tests and ANOVA F-test were used as appropriate. RESULTS: A total of 144/164 trainees participated (87.8%). The sample was 40.0%(n = 56) female and 57.9%(n = 81) male; 21.3%(n = 30) were PGY1, 22.0%(n = 31) PGY2, 24.8%(n = 35) PGY3, 18.4%(n = 26) PGY4, 13.5%(n = 19) PGY5. There were no significant differences in mean scale scores by gender for Mastery (3.3 vs 3.5; p = 0.17), or PAP (3.7 vs 3.5; p = 0.10), but mean PAV scores were significantly higher for females (3.6 vs 3.3; p = 0.04). While there were no significant differences in mean Mastery and PAP scale scores by training level (p = 0.44; p = 0.31), there was a significant difference in PAV scores (p < 0.01). The frequency of PAV feelings decreased over 5 years. CONCLUSIONS: Only PAV motivation differed by gender and training level. Understanding the psychology of motivation with this framework can aid both residents and programs in re-focusing on more adaptive learning strategies and supporting trainees in their transition to master surgeons.

Changed Landscapes of Surgical Education During COVID-19 Pandemic: Implications on Future Surgeons' Competence.

There has been a substantial impact on surgical education globally due to COVID-19 pandemic. The subtle and overt changes in surgical training programs during this pandemic along with its possible implications on the competence of future surgeons needs to be analyzed. If the essential measures are not taken in time, the surgical training programs are in a probable risk of failing to help surgery trainees successfully transition to the next phase of their surgical career. With a timely intervention for remediation, the surgery education programs will be sending surgical graduates into the community and society with the level of competency, expected from a surgeon despite COVID-19 pandemic. Keywords: COVID-19; surgical education; surgical simulation training.

Evaluation of an Antimicrobial Stewardship Program for Wound and Burn Care in Three Hospitals in Nepal.

Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Quality of Life Following Surgical Treatment of Post Cholecystectomy Bile Duct Injury.

BACKGROUND: The Roux-en-Y hepaticojejunostomy surgery provides the mainstay of treatment in cases of bile duct injury following cholecystectomy.The aim of this study is to assess the quality of life in patients who underwent surgical repair of bile duct injury following cholecystectomy. METHODS: The prospective cross sectional study was conducted in Gastrointestinal Surgery Unit, Bir Hospital, National Academy of Medical Sciences. The cases of bile duct injury following cholecystectomy who underwent surgical repair from April 2013 to March 2018 were included. The data collection was done using SF-36 quality of life questionnaire tool.The study was conducted after ethical clearance from Institutional Review Board of National Academy of Medical Sciences. RESULTS: There were 26 cases of referred bile duct injury admitted in gastrointestinal surgery department from 2013 April till 2018 March out of which 19 (73%) were included in the study.More than half of the patients had limitations in carrying out vigorous activities (as running or lifting heavy objects) and 5.2% had a lot of limitations in carrying our moderate activities (as moving a table).63.1% of the patients did not have any interference with social activities with family, friends, neighbors or social groups because of their physical health or emotional problems. CONCLUSIONS: The surgical repair of bile duct injury following laparoscopic cholecystectomy has an impact on ability to perform work or daily activities as a result of physical health. However, it has little impact on patient's perception of general health and social activities.

Surgical Education.

NA.

Streptococcus pneumoniae carriage prevalence in Nepal: evaluation of a method for delayed transport of samples from remote regions and implications for vaccine implementation.

BACKGROUND: Pneumococcal disease is a significant cause of morbidity and mortality in young children in Nepal, and currently available pneumococcal conjugate vaccines offer moderate coverage of invasive disease isolates. METHODS: A prevalence study of children aged 1.5 to 24 months in urban and rural Nepal was conducted. In the urban group, nasopharyngeal swabs (NPS) were transported using silica desiccant packages (SDP) with delayed processing (2 weeks), or skim-milk-tryptone-glucose-glycerin (STGG) with immediate processing (within 8 hours). Pneumococcal nasopharyngeal carriage prevalence, serogroup/type distribution and isolate genotypes (as defined by multilocus sequence typing) were determined. RESULTS: 1101 children were enrolled into the study: 574 in the urban group and 527 in the rural group. Overall carriage prevalence based on culture from specimens transported and stored in STGG was 58.7% (337/574), compared to 40.9% (235/574) in SDP. There was concordance of detection of pneumococcus in 67% of samples. Using the SDP method, pneumococcal carriage prevalence was higher in the rural population (69.2%; 364/526) compared to the urban population (40.9%; 235/574). Serogroup/type distribution varied with geographical location. Over half of the genotypes identified in both the urban and rural pneumococcal populations were novel. CONCLUSION: The combination of delayed culture and transport using SDP underestimates the prevalence of pneumococcal carriage; however, in remote areas, this method could still provide a useful estimate of carriage prevalence and serogroup/type distribution. Vaccine impact is unpredictable in a setting with novel genotypes and limited serotype coverage as described here. Consequently, continued surveillance of pneumococcal isolates from carriage and disease in Nepali children following the planned introduction of pneumococcal conjugate vaccines introduction will be essential.

Evaluation of haemophilus influenzae type b vaccine for routine immunization in Nepali infants.

BACKGROUND: Haemophilus influenzae type b (Hib) carriage and disease studies in Nepali children suggest a significant burden of infection. Hib conjugate vaccines (HibCV) do not have uniform immunogenicity between populations. We determined the immunogenicity of HibCV in Nepali infants, before its introduction into the routine immunization schedule. METHODS: Ninety infants recruited at Patan Hospital, Kathmandu, received 3 doses of the HibCV with routine immunizations (diphtheria, tetanus, whole cell pertussis-hepatitis B vaccine + oral polio vaccine) at 6, 10 and 14 weeks of age, and a HibCV booster at 52 weeks. Anti-polyribosylribitol phosphate (PRP) concentrations were measured at 18, 52 and 56 weeks, and the antibody persistence at 52 weeks was compared with antibody values in unimmunized controls (n = 30). RESULTS: After 3 doses of primary immunizations, at 18 weeks of age (n = 74), all infants had anti-PRP concentrations above the accepted thresholds for short- and long-term protection (0.15 and 1.0 µg/mL, respectively). At 1 year of age, before administration of the booster of HibCV, the anti-PRP geometric mean antibody concentration was 2.76 µg/mL (confidence interval: 1.88-4.07) in sera from the immunized children compared with 0.11 µg/mL (95% confidence interval: 0.08-0.17) in the nonimmunized control group (n = 30). Twenty-seven percent (20/74) of participants, however, had anti-PRP concentrations <1.0 µg/mL. Four weeks after the booster dose of HibCV, 98.5% of infants had anti-PRP concentrations above 1.0 µg/mL. CONCLUSION: Immunization with HibCV given as part of the Expanded Program on Immunization schedule in Nepal elicits robust antibody responses. Though the antibody wanes during the first year of life, most 1-year-old infants remain protected and respond robustly to a booster dose of the vaccine.

Spironolactone does not prevent acute mountain sickness: a prospective, double-blind, randomized, placebo-controlled trial by SPACE Trial Group (spironolactone and acetazolamide trial in the prevention of acute mountain sickness group).

OBJECTIVES: Over the last 20 years a number of small trials have reported that spironolactone effectively prevents acute mountain sickness (AMS), but to date there have been no large randomized trials investigating the efficacy of spironolactone in prevention of AMS. Hence, a prospective, double-blind, randomized, placebo-controlled trial was conducted to evaluate the efficacy of spironolactone in the prevention of AMS. METHODS: Participants were sampled from a diverse population of western trekkers recruited at 4300 m on the Mount Everest base camp approach (Nepal side) en route to the study endpoint at 5000 m. Three hundred and eleven healthy trekkers were enrolled, and 251 completed the trial from October to November 2007. Participants were randomly assigned to receive at least 3 doses of spironolactone 50 mg BID, acetazolamide 250 mg BID, or visually matched placebo. A Lake Louise AMS Score of 3 or more, together with the presence of headache and 1 other symptom, was used to evaluate the incidence and severity of AMS. Secondary outcome measures were blood oxygen content and the incidence and severity of high altitude headache (HAH). RESULTS: Acetazolamide was more effective than spironolactone in preventing AMS (OR = 0.28, 95% CI 0.12-0.60, p < 0.01). Spironolactone was not significantly different from placebo in the prevention of AMS. AMS incidence for placebo was 20.3%, acetazolamide 10.5%, and spironolactone 29.4%. Oxygen saturation was also significantly increased in the acetazolamide group (83% ± 0.04) vs spironolactone group (80% ± 0.05, p < 0.01). CONCLUSIONS: Spironolactone (50 mg BID) was ineffective in comparison to acetazolamide (250 mg BID) in the prevention of AMS in partially acclimatized western trekkers ascending to 5000 m in the Nepali Himalaya.