Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years


In Nigeria, access to open heart surgery (OHS) is adversely affected by insufficient blood and blood products, including the challenges because of the lack of patient-focused blood management strategies owing to the absent requisite point-of-care tests in the operating theatre (OR)/ICU. In addition, the limited availability of altruistic blood donors including the detection of transfusion transmitted infections more commonly among non-altruistic blood donors is another burden affecting the management of excessive bleeding during and after open heart surgery in our country.
The objective of this study was to review our local experience in the use of blood and blood products during open heart surgery and compare the same with the literature.Materials and methodsIn a period of 3 years (March, 2013-February, 2016), we performed a retrospective review of those who had open heart surgery in our institution. The data were obtained from our hospital health information technology department. The data comprised demography, types of operative procedures and units of blood and blood products transfused per procedure, including the details regarding the usage of the cell saver, as well as those who had severe bleeding requiring excessive blood transfusion.
During the study period, 102 patients had open heart surgery, an average of 34 cases in a year. Among them, there were 75 (73.53%) males and 37 (36.27%) females, giving a ratio of 2:1. The ages of the patients were from 0.6 (7/12) to 74 years. Mitral valve procedure was the most common (n=22, 21.6%) surgery type. Transfusion requirements averaged 1.9 units of fresh frozen plasma, 0.36 units of platelet concentrate, and 1.68 units of packed cells per procedure. The least common surgical procedure was common atrium repair (n=1, 0.01%).
Open heart procedure is a very complex procedure requiring cardiopulmonary bypass with associated severe perioperative bleeding. The attendant blood loss and haemostatic challenges are combated by intricate and selective transfusions of allogeneic blood and or blood products.

Factors contributing to disparities in mortality among patients with non-small-cell lung cancer.


Historically, non-small-cell lung cancer (NSCLC) patients who are non-white, have low incomes, low educational attainment, and non-private insurance have worse survival. We assessed whether differences in survival were attributable to sociodemographic factors, clinical characteristics at diagnosis, or treatments received. We surveyed a multiregional cohort of patients diagnosed with NSCLC from 2003 to 2005 and followed through 2012. We used Cox proportional hazard analyses to estimate the risk of death associated with race/ethnicity, annual income, educational attainment, and insurance status, unadjusted and sequentially adjusting for sociodemographic factors, clinical characteristics, and receipt of surgery, chemotherapy, and radiotherapy. Of 3250 patients, 64% were white, 16% black, 7% Hispanic, and 7% Asian; 36% of patients had incomes <$20 000/y; 23% had not completed high school; and 74% had non-private insurance. In unadjusted analyses, black race, Hispanic ethnicity, income <$60 000/y, not attending college, and not having private insurance were all associated with an increased risk of mortality. Black-white differences were not statistically significant after adjustment for sociodemographic factors, although patients with patients without a high school diploma and patients with incomes <$40 000/y continued to have an increased risk of mortality. Differences by educational attainment were not statistically significant after adjustment for clinical characteristics. Differences by income were not statistically significant after adjustment for clinical characteristics and treatments. Clinical characteristics and treatments received primarily contributed to mortality disparities by race/ethnicity and socioeconomic status in patients with NSCLC. Additional efforts are needed to assure timely diagnosis and use of effective treatment to lessen these disparities.

The role of diaspora and non-governmental organization in helping Sudanese children with congenital heart diseases: 6 years’ paediatric cardiac surgery camps experience


Background: Sudan one of the largest countries in Africa. In recent survey by Sudan Ministry of Health, congenital heart disease (CHD) was found to be one of the top eight diseases that lead to death of children in Sudan. The cost of surgical operation, follow up and diagnosis are expensive and this may result some children present with complications. The aim of this study is to assess the role of diaspora and non-governmental organization (NGO) in helping Sudanese children with CHD.
Methods: We assess the 6 years’ experience in charitable initiative established by Sudanese consultant pediatric intensivist and cardiologist working in Doha, Qatar in partnership with NGO in Gulf countries and Sudan. Examples of these organizations were Patient Helping Fund (PHF) the largest medical charity in Sudan, Eid Althani charity association in Qatar with collaboration of the Federal Ministry of Health (FMH), Ministry of Health in Khartoum and Gazira states. We established the program of providing suitable care for in need children.
Result: A total of 104 out of the 222 complex defects were considered for surgery, 118 underwent cardiac catheter interventions. The 30-days post-operative mortality was 14/222 (6.3%). The most essential post-surgical complications were postpericardiotomy syndrome, bleeding, and sepsis. Malnutrition poor socioeconomic status is significant factors negatively impact the outcomes. All surviving patients (n=208) remain in good clinical condition, and most are asymptomatic without any medications.
Conclusions: The collaboration of Sudanese pediatrician living outside Sudan with local and international NGOs can significantly improve child health in Sudan.

Challenges to providing open heart surgery for 186 million Nigerians


Background: Open heart surgery is nonexistent or undeveloped in many African countries due to the prerequisite for specialized multispecialty teams, expensive equipment, and consumables. This review aims to outline strategies for facilitating local skilled workforce training, improve patients’ access, and sustain heart surgery in Africa’s most populous nation. Methods: We reviewed the demographic, socioeconomic, and health metrics published by the United Nations, the World Health Organization (WHO), the World Bank, and other relevant sources for the top three African economies – South Africa, Nigeria, and Egypt. Results: South Africa classified as upper-middle-income nation with gross national income [GNI] $12,475–$4126 spends 8.8% of gross domestic product (GDP), while Egypt and Nigeria both classified as lower-middle-income nations GNI $4125–$1046 spends 5.6% and 3.7% of GDP, respectively, on health care. Egypt performed 45%, South Africa 39%, and Nigeria 0.1% of their WHO projected annual heart surgery volume in 2015. These capacities are consistent with the human development index (HDI), thoracic surgeon-to-population ratio, and health insurance coverage ranking of these countries. Conclusion: Although gross income per capita is comparable, the HDI – a better discriminator of development is higher in Egypt with 0.69 against 0.51 in Nigeria, as evidenced by their respective heart surgery capacities. While the WHO projected 72,000 cases/annum for Nigeria is unattainable with the present workforce, the Pan African Society for Cardiothoracic Surgery (PASCATS) 40/1 million population projection of 7200 cases/annum appears a more realistic goal. However achieving even this modest target will require government political willpower and increased budgetary allocation for expanding insurance coverage. PASCATS advocates three mentorship models: resident senior local consultant, mission teams and senior expatriate consultant, with centralization through regional referral centers as viable pathways to develop cardiac surgery in sub Saharan Africa. Regionalization optimizes the scarce workforce and resources and therefore by combining assets can fast track skill acquisition by trainee surgeons.

A case report of a polytrauma patient with penetrating iron rods in thorax and head


Impalement injury is an uncommon presentation, and penetrating chest injuries account for 1% to 13% of thoracic trauma hospital admissions. The vast majority of patients with penetrating thoracic trauma who survive to reach the hospital alive can be managed nonoperatively. Nevertheless, in 10% to 15% of cases, emergency operation is necessary due to the associated hemorrhagic shock and visceral injury.
Here, we report on a 39-year-old male, a construction worker, who fell down from a height of a construction site, landing ventrally on a clump of iron rods with 4 projecting heavy metallic rods penetrating into his thorax and head (scalp pierced only). Emergency surgery was taken, and the patient had an uneventful successful outcome.
After massive thoracic impalement, rapid transportation to a tertiary trauma center with the impaled objects in situ can improve the outcome. Video-assisted thoracic surgery (VATS) is recommended to remove the foreign body under direct vision and to reduce the incidence of missed, potentially fatal vascular or visceral injuries.

Lung squamous cell carcinoma with solitary ocular metastasis and its successful treatment with thoracic surgery and chemotherapy: an interesting and rare case report


The incidence of ocular metastasis from lung cancer is reported to be 0.1-7%, with adenocarcinoma and small cell lung cancer accounting for the highest proportions of these cases. The majority of cases involves metastasis to more than one other distal organ in addition to the eye. Here, we report for the first time, a case of lung squamous cell carcinoma with solitary symptomatic ocular metastasis as the initial manifestation that was managed by a multidisciplinary treatment (MDT).
A woman presented at the ophthalmology department of hospital with a 1-week history of left eye pain and blurred vision. Systemic examination led to the diagnosis of central lung cancer in the right lower lobe with ocular metastasis. After consultations with an MDT, including specialists from the surgery, internal medicine, ophthalmology, radiotherapy and imaging departments, the patient underwent surgery and chemotherapy. Her eye symptoms disappeared, and the ocular lesion was well controlled without any specific ocular treatment. The patient demonstrated a prolonged progression-free survival.
This is the first report of a rare case with solitary ocular metastasis as the initial manifestation of lung squamous cell carcinoma. This rare patient was treated based on evidence-based medicine, indicating the importance of cooperation within an MDT. The successful treatment of this case was reported as a new therapeutic reference for clinicians who encounter similar cases in the future.

Global Unmet Needs in Cardiac Surgery.


More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

Effects of Socioeconomic Status on Clinical Outcomes with Ventricular Assist Devices.


Lower socioeconomic status (SES) is a known risk factor for worse outcomes after major cardiovascular interventions. Furthermore, individuals with lower SES face barriers to evaluation for advanced heart failure therapies, including ventricular assist device (VAD) implantation.Examination of the effects of individual determinants of SES on VAD outcomes will show similar survival benefit in patients with lower compared with higher SES.All VAD implants at the University of Florida from January 2008 through December 2015 were reviewed. Patient-level determinants of SES included place of residence, education level, marital status, insurance status, and financial resources stratified by percent federal poverty level. Survival or transplantation at 1 year, 30-day readmission, implant length of stay (LOS), and an aggregate of VAD-related complications were assessed in univariate fashion and multivariable regression modelling.A total of 111 patients were included (mean age at time of implant 57.6 years, 82.8% men). More than half received destination therapy. At 1 year, 78.3% were alive on device support or had undergone successful transplantation. There were no differences in survival, 30-day readmission, or aggregate VAD complications by SES category. Although patients with lower levels of education had longer LOS in univariate analysis, on multivariable ordinal regression modelling, this relationship was no longer seen.Patients with lower SES receive the same survival benefit from VAD implantation and are not more likely to have 30-day readmissions, complications of device support, or prolonged implant LOS. Therefore, VAD implantation should not be withheld based on these parameters alone.

The Cape Town Declaration on Access to Cardiac Surgery in the Developing World.


Twelve years after cardiologists and cardiac surgeons from all over the world issued the ‘Drakensberg Declaration on the Control of Rheumatic Fever and Rheumatic Heart Disease in Africa’, calling on the world community to address the prevention and treatment of rheumatic heart disease (RHD) through improving living conditions, to develop pilot programmes at selected sites for control of rheumatic fever and RHD, and to periodically review progress made and challenges that remain, RHD still accounts for a major proportion of cardiovascular diseases in children and young adults in low- and middle-income countries, where more than 80% of the world population live. Globally equal in prevalence to human immunodeficiency virus infection, RHD affects 33 million people worldwide. Prevention efforts have been important but have failed to eradicate the disease. At the present time, the only effective treatment for symptomatic RHD is open heart surgery, yet that life-saving cardiac surgery is woefully absent in many endemic regions. In this declaration, we propose a framework structure to create a co-ordinated and transparent international alliance to address this inequality.

Global Incidence and Outcomes of Adult Patients With Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-Analysis.


OBJECTIVES:
To estimate the global incidence and outcomes of acute kidney injury (AKI) after cardiac surgery in adult patients.

DESIGN:
A systematic review and meta-analysis.

SETTING:
Cardiac surgery wards.

PARTICIPANTS:
Adult patients after cardiac surgery

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
The authors searched PubMed, Web of Science, Cochrane Library, OVID, and EMBASE databases for all articles on cardiac surgery patients published during 2004 to 2014. Meta-analyses were conducted to generate pooled incidence, mortality, ICU length of stay, and length of hospital stay. The authors also described the variations according to study design, criteria of AKI, surgical methods, countries, continents, and their economies. After a primary and secondary screen, 91 observational studies with 320,086 patients were identified. The pooled incidence rates of AKI were 22.3% (95% confidence interval [CI], 19.8 to 25.1) in total and 13.6%, 3.8%, and 2.7% at stages 1, 2, and 3, respectively, whereas 2.3% of patients received renal replacement therapy. The pooled short-term and long-term mortality were 10.7% and 30%, respectively, and increased along with the severity of stages. The pooled unadjusted odds ratio for short-term and long-term mortality in patients with AKI relative to patients without AKI was 0.144 (95% CI, 0.108 to 0.192, p<0.001) and 0.342 (95% CI 0.287-0.407, p<0.001), respectively. The pooled average ICU length of stay and length of hospital stay in the AKI group were 5.4 and 15 days, respectively, while they were 2.2 and 10.5 days in the no-AKI group.

CONCLUSIONS:
AKI is a great burden for patients undergoing cardiac surgery and can affect short-term and long-term prognoses of these patients.