Training and accrediting international surgeons.

BACKGROUND: Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification. METHODS: MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: 'credentialing', 'education', 'global surgery', 'international medicine', 'international surgery' and 'training'. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons. RESULTS AND CONCLUSION: The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.

Conditions, preventable deaths, procedures and validation of a countrywide survey of surgical care in Nepal.

BACKGROUND: To determine a true denominator of worldwide surgical need, it is imperative to include estimations at a population-based level, to capture those individuals unable to access surgical care. This study was designed to validate the Surgeons OverSeas Assessment of Surgical need (SOSAS) tool with the addition of a visual physical examination, and describe the prevalence of surgical conditions, deaths possibly averted with access to surgical care, and the number of surgical procedures performed annually, in Nepal. METHODS: The SOSAS tool, developed to measure the prevalence of surgical conditions at a population level and used in two African countries, was employed. Fifteen of the 75 districts of Nepal were chosen proportional to population. Responses were recorded for the head of the household for demographic information and recalled deaths, and two randomly selected household members underwent a verbal head-to-toe interview for surgical conditions and a visual physical examination by a trained physician. RESULTS: A total of 1350 households were surveyed (2695 respondents). Observed agreement between the verbal response and physical examination findings was 94·6 per cent. Some 10·0 (95 per cent c.i. 8·9 to 11·2) per cent of respondents had a current condition requiring surgical care and 23 per cent of deaths may have been averted with proper access to surgical care. An estimated 291·8 major operations per 100 000 population are performed annually in Nepal. CONCLUSION: The visual physical examination component validated the SOSAS tool, and justified the estimates of previous studies in Sierra Leone and Rwanda. These data provide insights into the health needs of Nepal and provide evidence to develop surgical programmes, assist with monitoring and evaluation, and help with advocacy for increased resources in Nepal.

Burns in Nepal: A population based national assessment.

BACKGROUND: Burns are ranked in the top 15 leading causes of the burden of disease globally, with an estimated 265,000 deaths annually and a significant morbidity from non-fatal burns, the majority located in low and middle-income countries. Given that previous estimates are based on hospital data, the purpose of this study was to explore the prevalence of burns at a population level in Nepal, a low income South Asian country. METHODS: A cluster randomized, cross sectional countrywide survey was administered in Nepal using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) from May 25th to June 12th, 2014. Fifteen of the 75 districts of Nepal were randomly chosen proportional to population. In each district, three clusters, two rural and one urban, were randomly selected. The SOSAS survey has two portions: the first collects demographic data about the household's access to healthcare and recent deaths in the household; the second is structured anatomically and designed around a representative spectrum of surgical conditions, including burns. RESULTS: In total, 1350 households were surveyed with 2695 individuals with a response rate of 97%. Fifty-five burns were present in 54 individuals (2.0%, 95% CI 1.5-2.6%), mean age 30.6. The largest proportion of burns was in the age group 25-54 (2.22%), with those aged 0-14 having the second largest proportion (2.08%). The upper extremity was the most common anatomic location affected with 36.4% of burns. Causes of burns included 60.4% due to hot liquid and/or hot objects, and 39.6% due to an open fire or explosion. Eleven individuals with a burn had an unmet surgical need (20%, 95% CI 10.43-32.97%). Barriers to care included facility/personnel not available (8), fear/no trust (1) and no money for healthcare (2). CONCLUSION: Burns in Nepal appear to be primarily a disease of adults due to scalds, rather than the previously held belief that burns occur mainly in children (0-14) and women and are due to open flames. This data suggest that the demographics and etiology of burns at a population level vary significantly from hospital level data. To tackle the burden of burns, interventions from all the public health domains including education, prevention, healthcare capacity and access to care, need to be addressed, particularly at a community level. Increased efforts in all spheres would likely lead to a significant reduction of burn-related death and disability.

Case report: prenatally detected dumdbell-shaped retroperitoneal duplication cyst.

Enteric duplication cysts are infrequently located in the retroperitoneum. Such cysts are typically spherical or ovoid. We report a retroperitoneal duplication cyst with extension across the abdominal midline in a previously unreported dumbbell configuration. This is the third reported case of prenatally detected retroperitoneal enteric duplication cyst.

TGF-beta1 alters the healing of cutaneous fetal excisional wounds.

BACKGROUND/PURPOSE: In a number of species, fetal wound healing differs from the adult in the absence of inflammation, fibrosis, scar formation, and excisional wound contraction. The lack of inflammation also may explain the relative absence of any cytokine levels at the wound site, such as transforming growth factor (TGF)-beta, and therefore the unique characteristics of fetal wound healing. The authors hypothesized that exogenous TGF-beta1 would induce contraction, inflammation, fibrosis, and scar formation in cutaneous excisional wounds in the fetal rabbit. METHODS: Cellulose discs (3 mm in diameter) were formulated with either 1.0 microg TGF-beta1 (n = 6) or bovine serum albumin (BSA; n = 7), as a control, for sustained-release over 3 days. Each disc was implanted into the subcutaneous tissue on the backs of fetal New Zealand White Rabbits in utero on day 24 of gestation (term, 31 days). A full-thickness, 3-mm excisional wound (7.4 mm2) was then made next to the implanted cellulose disc. All wounds were harvested 3 days later. RESULTS: At harvest, the excisional wounds in the TGF-beta1 group had contracted (5.6 +/- 2.0 mm2), whereas those in the control group had expanded (13.5 +/- 1.2 mm2, P< .01). The surrounding dermis in the TGF-beta1 group had 16.3 inflammatory cells per grid block compared with 12.4 cells in the control group (not significant). In addition, a greater amount of fibrosis was induced by the TGF-beta1 implant (1.7 +/- 0.3) than the control implant (0.4 +/- 0.2) on a scale of 0 to 3, P < .01. In situ hybridization analysis showed an increase in procollagen type 1alpha1 gene expression in the surrounding dermis of the TGF-beta1 group (36.7 +/- 3.6 grains per grid block) compared with the control group (7.1 +/- 0.9 grains per grid block, P < .001). CONCLUSIONS: These results demonstrate that the cytokine TGF-beta1 can induce fetal excisional wounds to contract, stimulate fibrosis, and increase procollagen type 1alpha1 gene expression. These findings further suggest that the absence of TGF-beta1 atthe wound site may be responsible in part for the lack of a postnatal healing response.

MMP-8 is the predominant collagenase in healing wounds and nonhealing ulcers.

BACKGROUND: The initial cleavage of collagen by collagenase represents the rate-limiting step in the degradation of this central extracellular matrix protein. Chronic nonhealing ulcers, especially pressure ulcers, typically contain elevated levels of collagenolytic activity. However, there have been no detailed attempts to identify the source of these collagenases and their activity either in normal healing wounds or in chronic nonhealing ulcers. MATERIALS AND METHODS: Levels of the matrix metalloproteinases, MMP-1 and MMP-8, and the tissue inhibitor of matrix metalloproteinases, TIMP-1, were measured in fluids and tissues of healing human wounds and nonhealing ulcers by ELISA. Relative MMP-1 and MMP-8 levels were also analyzed by substrate preference in a functional assay. RESULTS: The patterns of the collagenases MMP-1 and MMP-8 in healing wounds were distinct, with MMP-8 appearing in significantly greater amounts than MMP-1. Chronic nonhealing ulcers were characterized by significantly higher levels of MMP-1 and MMP-8, and lower levels of TIMP-1, than in healing wounds. Levels of both MMP-1 and MMP-8 varied greatly in chronic ulcers, although MMP-8 was always the predominant collagenase present in these wounds. Interestingly, these collagenases were present almost exclusively in their inactive forms in healing wounds, whereas nonhealing ulcers possessed significant levels of the active forms of these enzymes. CONCLUSIONS: These results clearly demonstrate that the neutrophil-derived MMP-8 is the predominant collagenase present in normal healing wounds and suggest that overexpression and activation of this collagenase may be involved in the pathogenesis of nonhealing chronic ulcers. In addition, excessive collagenolytic activity in chronic ulcers is made possible, partly because of the reduced levels of the inhibitor, TIMP-1.

The proteolytic environment of chronic wounds.

A consistent feature of chronic leg and pressure ulcers is chronic inflammation associated with an elevated infiltration of neutrophils. Neutrophils and their proteases have been implicated in mediating the tissue damage associated with a variety of chronic inflammatory diseases. This review discusses our current understanding of the proteolytic enzymes found in chronic wounds and attempts to relate this information to the abundant presence of neutrophils. In addition, the implications that the proteolytic environment may have for current and future treatment strategies of chronic nonhealing wounds are discussed.

Dynamics of the matrix metalloproteinases MMP-1 and MMP-8 in acute open human dermal wounds.

Extracellular matrix degradation during dermal wound healing involves multiple levels of regulation by several enzymes of the matrix metalloproteinase family, their activators, and their inhibitors. This study tested the hypothesis that a temporal pattern of interstitial collagenase appearance occurs during normal dermal wound healing, with matrix metalloproteinase-8 originating from neutrophils appearing earlier than the fibroblast-derived matrix metalloproteinase-1. Open (6 mm) full-thickness dermal wounds, which were covered by transparent occlusive dressings, were made in healthy human volunteers (n = 20). Wound fluids from under the dressings were collected daily through day 8, and wound tissue biopsies were obtained on days 0, 2, 4, 14, and 28. Collagenases were extracted from homogenized tissue biopsies for analysis. Samples were analyzed for the presence of matrix metalloproteinase-1 and matrix metalloproteinase-8 by enzyme-linked immunosorbent assays and by collagenase activity assays using purified types I and III collagen as substrates. In addition, tissue inhibitor of metalloproteinases-1 and matrix metalloproteinase-1/tissue inhibitor of metalloproteinases-1 complexes in wound fluids were measured. Results showed a differential temporal pattern of matrix metalloproteinase-1 and matrix metalloproteinase-8 in wound exudates with peak levels of matrix metalloproteinase-8 occurring on day 4 and matrix metalloproteinase-1 peak levels on day 7. Maximal levels in tissue for both enzymes occurred on day 2. At all time points examined, levels of matrix metalloproteinase-8 were statistically higher than matrix metalloproteinase-1 (100-fold to 200-fold). Tissue inhibitor of metalloproteinases-1 levels declined over time, whereas levels of matrix metalloproteinase-1/tissue inhibitor of metalloproteinase-1 complexes increased to a plateau on day 7. This study provides new evidence implicating matrix metalloproteinase-8 as a major collagenase in healing human dermal wounds. It also shows a temporal pattern in the appearance of the matrix metalloproteinases, tissue inhibitor of metalloproteinase-1, and matrix metalloproteinase-1/tissue inhibitor of metalloproteinases-1 complexes, suggesting that a tightly regulated pattern of expression of matrix metalloproteinases and their inhibitors is essential for normal wound healing in humans.

Physiology of the chronic wound.

There is as yet no unified mechanism that explains the pathophysiology of every nonhealing wound. This is largely because many of the basic biological investigations in this area have only been undertaken seriously in the past few years and many phenomena remain unexplained. As new data become available, these theoretical models undoubtedly will continue to evolve. However, a clear understanding of the facts presently available should provide the clinician with a good scientific basis for rational clinical interventions. There is an urgent need to bridge the gap that often exists between laboratory research and clinical practice. A number of wound care practices, which have been shown to be ineffective or harmful, are still widely used. This includes the application of toxic wound cleansing agents, inappropriate use of topical antibiotics, and the practice of wet-to-dry dressings. The past 2 decades have witnessed an unprecedented proliferation of wound care products, few of which have be proven to be consistently superior to simpler and more cost-effective measures. For the foreseeable future, the search for the magic wound 'portions and lotions' probably will continue to revolve around topical growth factor and antiprotease therapy. However, such efforts will only come to fruition when we truly understand the pathophysiologic basis for abnormal wound healing.