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The year 2015 was pivotal for the growth of global neurosurgery. In January, the United Nations (UN) adopted the Sustainable Development Goals (SDGs), replacing the expiring Millennial Development Goals. The SDGs were more comprehensive, having 17 Goals with 169 associated targets; a significant number of these included the necessity for surgical care to achieve the targets. 1 In early Spring 2015, publication of Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development - The Lancet Commission on Global Surgery created a paradigm shift in the understanding of surgical needs worldwide, particularly in access to safe, timely and affordable surgical care for billions of individuals and large gaps in global surgical health workforce.2 At around the same time, Disease Control Priorities 3rd Edition, Volume 1, Essential Surgery laid out the economic case for surgical care, particularly in low resource settings.3 In May, the 68th World Health Assembly unanimously approved WHA resolution 68.15 on strengthening emergency and essential surgical care as a component of universal health coverage.4 The adoption of SDGs and WHA 68.15 provided the political impetus toward making surgical care a global priority, DCP3 created the health economic basis for global surgical care, and the Lancet Commission developed the factual needs basis for greatly enlarging global surgical service delivery. The World Health Organization (WHO) is the health technical arm of the UN. The WHA is composed of the health ministers of all UN Member States (countries) and is the governing body of WHO, setting the global health agenda and steering WHO’s work. The WHO Emergency and Essential Surgical Care (EESC) Programme5 was given the mandate to implement WHA resolution 68.15; a task that could only be achieved through extensive worldwide partnerships, such as the World Federation of Neurosurgical Societies (WFNS), which has official working relations as a non-state actor with WHO.6 September 9-12, 2015, the 15th Interim Meeting of the World Federation of Neurosurgical Societies (WFNS) met in Rome, Italy.7 For the first time, a neurosurgeon was Lead of WHO EESC, creating a unique opportunity for optimally augmenting this WHO/WFNS partnership going forward. The Foundation for International Education in Neurosurgery (FIENS) held a session during this meeting, further highlighting future prospects.

Background Surgical care is a cost-effective intervention with major public health impact. Yet, five billion people do not have access to surgical and anesthesia care. This overwhelming unmet need has generated a rising interest in scale-up of these services globally. The purpose of this research was to aggregate available guidelines and create a synthesized tool that could provide valuable information at the local, national, and international health system levels. Methods A systematic review identified current documents cataloging elements for surgical care provision. Items with a reported frequency of >30% were included in the initial draft of the Surgical Assessment Tool. This underwent two cycles of Delphi-method expert opinion elicitation from providers working in low- and middle-income settings. Finally, the tool underwent vetting by the World Health Organization to create an expert-endorsed survey. Results Fifteen surgical tools were identified, containing a total of 216 unique elements in the following domains: infrastructure (n = 152), service delivery (n = 49), and workforce (n = 15). The final tool consisted of 169 items in the following domains: infrastructure (n = 35), service delivery (n = 92), workforce (n = 20), information management (n = 10), and financing (n = 12). Conclusion Informed planning is critical to ensure successful expansion of surgical services. Our analysis of current tools shows varying agreement on the essential components of surgical care delivery. This updated tool serves as a crucial method to systematically assess surgical systems as well as monitor, modify, and strengthen in a scalable fashion. Importantly, it has the potential to be used in all settings after adaptation to local context.

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care's dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.Les soins de santé primaires établissent le cadre requis pour des soins complets adaptés aux patients, gages d'un système de santé solide. Ils jouent donc un rôle central dans la mise en place d'une couverture maladie universelle. Dans ce contexte, les médecins de famille sont les mieux placés pour incarner une double perspective, la santé communautaire et la santé des populations, car ils travaillent souvent dans des hôpitaux ruraux ou de district qui disposent de ressources humaines limitées, surtout en termes de spécialistes. Le présent document montre dans quelle mesure une formation complémentaire dédiée aux médecins de famille, acteurs clés des soins de santé primaires, peut avoir un impact décisif sur la diminution des inégalités d'accès aux interventions chirurgicales, obstétriques et anesthésiques dans les pays à faible et moyen revenu, ainsi que dans les milieux ruraux ou isolés. Il existe de nombreux exemples qui illustrent la façon dont les programmes de formation peuvent être mis en œuvre dans les endroits manquant de ressources afin que les médecins de famille acquièrent des compétences chirurgicales vitales, et qui indiquent comment les médecins de famille des pays à haut revenu peuvent apprendre des techniques de chirurgie essentielles pour travailler outre-mer ou dans des régions plus défavorisées. Les législateurs devraient promouvoir la pratique chirurgicale chez les médecins de famille en soutenant les programmes qui incluent une formation complémentaire aux techniques de chirurgie, et en multipliant les opportunités et sources de motivation pour que les médecins de famille exercent dans les zones rurales. Par ailleurs, les projets nationaux devraient comporter une stratégie de soins de santé primaires pour les actes chirurgicaux et, globalement, les médecins de famille devraient être pris en compte dans les discussions consacrées aux interventions chirurgicales. Enfin, chirurgiens, anesthésistes, obstétriciens et médecins de famille devraient être encouragés à collaborer pour s'assurer que tous les patients, quel que soit leur lieu de résidence, puissent bénéficier de soins chirurgicaux au moment opportun et en toute sécurité.La atención primaria de salud establece el marco para la prestación de una atención socialmente informada, integral y centrada en el paciente, que es la base de los sistemas sólidos de atención sanitaria y, por lo tanto, es fundamental para lograr la cobertura sanitaria universal. Los médicos de familia son los que mejor pueden asumir el doble enfoque de la atención primaria en la salud de la comunidad y de la población porque trabajan con frecuencia en hospitales rurales o de distrito que tienen recursos humanos limitados, en especial por la falta de especialistas. En este documento, se pretende ilustrar cómo la capacitación adicional de los médicos de familia, quienes son los profesionales clínicos clave en la atención primaria, puede desempeñar una función esencial en la reducción de las desigualdades que existen para acceder a los procedimientos quirúrgicos, obstétricos y de anestesia en los países de ingresos bajos y medios y en los zonas rurales o remotas. También se dan ejemplos de cómo se pueden elaborar programas de capacitación en entornos de bajos recursos para preparar a los médicos de familia con técnicas quirúrgicas que salvan vidas y de cómo se puede capacitar a los médicos de familia de los países de altos ingresos sobre las técnicas quirúrgicas esenciales para que trabajen en el extranjero en entornos de bajos ingresos. Los responsables de formular políticas deben promover la práctica quirúrgica entre los médicos de familia mediante su apoyo a los programas de medicina familiar que incluyan una capacitación adicional sobre técnicas quirúrgicas, así como la ampliación de las oportunidades y de los incentivos para que los médicos de familia presten servicios en las zonas rurales. Además, los planes quirúrgicos nacionales deben incluir una estrategia de atención primaria de salud para la intervención quirúrgica y, a nivel mundial, los médicos de familia se deben tener en cuenta en los debates sobre la intervención quirúrgica. Por último, se debe alentar a los cirujanos, anestesiólogos, obstetras y médicos de familia a que colaboren para garantizar que todos los pacientes, sea cual sea su lugar de residencia, reciban servicios quirúrgicos seguros y oportunos.توفر الرعاية الصحية الأولية الإطار المطلوب لتقديم الرعاية الشاملة، الواعية اجتماعياً، والتي تركز على المريض، والتي تعتمد على أنظمة الرعاية الصحية الفعالة، وبالتالي فهي مركزية لتحقيق التغطية الصحية الشاملة. يعتبر طبيب الأسرة في وضع أفضل لتجسيد التركيز الثنائي للرعاية الصحية الأولية على صحة المجتمع والسكان، وذلك لأنه غالبًا ما يعمل في مستشفيات ريفية أو محلية تعاني من موارد بشرية محدودة، وبخاصة نقص في المتخصصين. نريد هنا أن نوضح كيف يمكن للتدريب الإضافي لطبيب الأسرة، والأطباء السريريين الرئيسيين في الرعاية الأولية، أن يلعبوا دورًا حاسمًا في الحد من التفاوتات في الحصول على الرعاية في العمليات الجراحية، وعمليات التوليد، والتخدير في البلدان ذات الدخل المنخفض والمتوسط، وفي المناطق الريفية أو النائية. يتم تقديم أمثلة على كيفية تطوير برامج التدريب في الأماكن منخفضة الموارد، لتزويد طبيب الأسرة بالمهارات الجراحية المنقذة للحياة، وكيف يمكن تدريب طبيب الأسرة في البلدان ذات الدخل المرتفع على المهارات الجراحية الأساسية للعمل في الخارج في البلدان ذات الدخل المنخفض. يجب على واضعي السياسات الارتقاء بالممارسات الجراحية بين أطباء الأسرة من خلال دعم برامج الطب الأسري، والتي تشمل تدريبًا على المهارات الجراحية الإضافية، ومن خلال توسيع الفرص والحوافز لطبيب الأسرة ليعمل في المناطق الريفية. وبالإضافة إلى ذلك، فإنه يجب أن تشتمل الخطط الجراحية الوطنية على استراتيجية للرعاية الصحية الأولية خاصة بالرعاية الجراحية، كما يجب على الصعيد العالمي وضع طبيب الأسرة في الاعتبار في نقاشات الرعاية الجراحية. وفي النهاية، يجب تشجيع الجراحين، وأطباء التخدير، وأطباء التوليد، وأطباء الأسرة، على التعاون لضمان حصول جميع المرضى، بغض النظر عن أماكن إقامتهم، على رعاية جراحية آمنة، وفي الوقت المناسب.初级卫生保健为在健全的卫生保健体系的基础上提供社会知情、全面的、以患者为中心的保健服务提供了框架，因此对实现全民健康覆盖至关重要。家庭医生最适合体现初级卫生保健对社区和人民卫生双重关注，因为他们通常受雇于人力资源有限的农村或地区医院，尤其缺乏专科医生。在此，我们想阐明对家庭医生（初级保健的主要临床医生）进行额外培训如何能够在缩小中低收入国家以及农村或偏远地区在获得外科、产科和麻醉护理的差距方面发挥关键作用。例如，如何在资源匮乏的环境下制定培训计划，以助家庭医生掌握挽救生命的手术技能，以及如何向高收入国家的家庭医生进行其在海外低收入国家工作所必需的外科技能培训。决策者应通过支持家庭医学计划（包括额外的外科技能培训）以及为家庭医生提供更多到农村地区服务的机会和激励措施，推动家庭医生的外科手术实践。此外，国家外科手术计划应涵盖外科手术护理的初级卫生保健战略，且全球各国在讨论外科手术治疗时都应将家庭医生考虑在内。最后，应鼓励外科医生、麻醉师、妇产科医生和家庭医生合作，以确保所有患者无论居住在哪，都可获得安全及时的手术护理。.Первичная медико-санитарная помощь обеспечивает основу для оказания социально информированной, комплексной и ориентированной на пациента помощи, лежащей в основе надежных систем здравоохранения, и поэтому играет центральную роль в достижении всеобщего охвата услугами здравоохранения. Семейные врачи наилучшим образом подходят для воплощения двойной ориентации первичной медико-санитарной помощи в вопросах здравоохранения сообщества и населения, поскольку они часто работают в сельских или районных больницах с ограниченными кадровыми ресурсами, в частности им недостает специалистов. Здесь мы хотим показать, как дополнительное обучение семейных врачей (основных врачей первичной медико-санитарной помощи) может сыграть решающую роль в сокращении неравенства доступа к хирургической, акушерской и анестезиологической помощи в странах с низким и средним уровнем доходов, а также в сельских или удаленных районах. Приведены примеры того, как можно разработать программы обучения в районах с низким уровнем ресурсов, чтобы вооружить семейных врачей хирургическими навыками, нужными для спасения жизни, и как семейные врачи в странах с высоким уровнем доходов могут обучаться хирургическим навыкам, необходимым для работы за границей в регионах с низким уровнем доходов. Лица, формирующие политику, должны продвигать хирургическую практику среди семейных врачей путем поддержки программ семейной медицины, которые включают дополнительное обучение хирургическим навыкам, а также путем расширения возможностей и стимулов для работы семейных врачей в сельских районах. Более того, национальные планы хирургической помощи должны включать стратегию первичной медико-санитарной помощи в отношении хирургической помощи, а в глобальном масштабе необходимо учитывать семейных врачей при обсуждении вопросов хирургической помощи. И наконец, следует поощрять к сотрудничеству хирургов, анестезиологов, акушеров и семейных врачей для обеспечения того, чтобы все пациенты, независимо от места проживания, получали безопасную и своевременную хирургическую помощь.

Purpose of review Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management. Recent findings Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery. Summary Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.

Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define—for the first time—the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. Methods and findings The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries—who only made up 21% of the total attendees. Conclusions To track global progress towards timely access to quality SAO care, these indicators—at the basic level—should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies., Justine Davies and colleagues discuss the development of updated indicators to support global achievement of access to safe surgical, anaesthetic, and obstetric care.

Approximately 5 billion people do not have access to safe, timely, and affordable surgical and anesthesia care, with this number disproportionately affecting those from low–middle-income countries (LMICs). Perioperative mortality rates (POMRs) have been identified by the World Health Organization as a potential health metric to monitor quality of surgical care provided. The purpose of this systematic review was to evaluate published reports of POMR and suggest recommendations for its appropriate use as a health metric. The protocol was registered a priori with PROSPERO. A peer-reviewed search strategy was developed adhering with the PRISMA guidelines. Relevant articles were identified through Medline, Embase, CENTRAL, CDSR, LILACS, PubMed, BIOSIS, Global Health, Africa-Wide Information, Scopus, and Web of Science databases. Two independent reviewers performed a primary screening analysis based on titles and abstracts, followed by a full-text screen. Studies describing POMRs of adult emergency abdominal surgeries in LMICs were included. A total of 7787 articles were screened of which 7466 were excluded based on title and abstract. Three hundred and twenty-one articles entered full-text screen of which 70 articles met the inclusion criteria. Variables including timing of POMR reporting, intraoperative mortality, length of hospital stay, complication rates, and disease severity score were collected. Complication rates were reported in 83% of studies and postoperative stay in 46% of studies. 40% of papers did not report the specific timing of POMR collection. 7% of papers reported on intraoperative death. Additionally, 46% of papers used a POMR timing specific to the duration of their study. Vital signs were discussed in 24% of articles, with disease severity score only mentioned in 20% of studies. POMR is an important health metric for quantifications of quality of care of surgical systems. Further validation and standardization are necessary to effectively use this health metric.

OBJECTIVEWorldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.METHODSResults from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.RESULTSEvery year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases—all in low- and middle-income countries—that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.CONCLUSIONSEach year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.

BACKGROUND Many health care facilities in low- and middle-income countries are inadequately resourced. COVID-19 has the potential to decimate surgical health care services unless health systems take stringent measures to protect health care workers from viral exposure and ensure the continuity of specialized care for patients. Among these measures, the timely diagnosis of COVID-19 is paramount to ensure the use of protective measures and isolation of patients to prevent transmission to health care personnel caring for patients with an unknown COVID-19 status or contact during the pandemic. Besides molecular and antibody tests, chest computed tomography (CT) has been assessed as a potential tool to aid in the screening or diagnosis of COVID-19 and could be valuable in the emergency care setting. OBJECTIVE This paper presents the protocol for an umbrella review that aims to identify and summarize the available literature on the diagnostic accuracy of chest CT for COVID-19 in trauma surgery patients requiring urgent care. The objective is to inform future recommendations on emergency care for this category of patients. METHODS We will conduct several searches in the L·OVE (Living Overview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials, and over 30 other sources. The search results will be presented according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis). This review will preferentially consider systematic reviews of diagnostic test accuracy studies, as well as individual studies of such design, if not included in the systematic reviews, that assessed the sensitivity and specificity of chest CT in emergency trauma surgery patients. Critical appraisal of the included studies for risk of bias will be conducted. Data will be extracted using a standardized data extraction tool. Findings will be summarized narratively, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be used to grade the certainty of evidence. RESULTS Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in October 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish the findings in a peer-reviewed journal and present our results at conferences that engage the most pertinent stakeholders. CONCLUSIONS During the COVID-19 pandemic, protecting health care workers from infection is essential. Up-to-date information on the efficacy of diagnostic tests for detecting COVID-19 is essential. This review will serve an important role as a thorough summary to inform evidence-based recommendations on establishing effective policy and clinical guideline recommendations. CLINICALTRIAL PROSPERO International Prospective Register of Systematic Reviews CRD42020198267; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=198267 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/25207

ANTECEDENTES: El contexto de un ensayo aleatorio puede determinar si sus hallazgos son generalizables y, por lo tanto, pueden aplicarse a diferentes entornos. La contribucion de los paises de ingresos bajos y medianos (PIBM) a los ensayos aleatorizados de neurocirugia no se ha descrito sistematicamente antes. OBJETIVO: Realizar un analisis sistematico de las caracteristicas del diseno y la metodologia, la fuente de financiacion y las intervenciones estudiadas entre los ensayos dirigidos y / o realizados en paises de altos ingresos (HIC) frente a LMIC. METODOS: Desde enero de 2003 hasta julio de 2016, los ensayos en ingles con> 5 pacientes que evaluaban cualquier procedimiento neuroquirurgico frente a otro procedimiento, tratamiento no quirurgico o ningun tratamiento se recuperaron de MEDLINE, Scopus y Cochrane Library. La clasificacion de ingresos de cada pais se evaluo mediante el metodo Atlas del Banco Mundial. RESULTADOS: Un total de 73,3% de los 397 estudios que cumplieron con los criterios de inclusion fueron dirigidos por paises de ingresos bajos, mientras que el 26,7% fueron dirigidos por paises de ingresos bajos y medianos. Si se excluye a China, solo el 8,8% fueron liderados por paises de ingresos bajos y medianos. Los ensayos dirigidos por HIC inscribieron una mediana de 92 pacientes frente a una mediana de 65 pacientes en los ensayos dirigidos por LMIC. Ensayos dirigidos por HIC inscritos en 7,6 sitios frente a 1,8 sitios en estudios dirigidos por LMIC. Mas de la mitad de los ensayos dirigidos por LMIC fueron financiados institucionalmente (54,7%). La mayoria de los ensayos dirigidos por HIC y LMIC evaluaron la neurocirugia espinal, 68% y 71,7%, respectivamente. CONCLUSION: Hemos establecido que existe una disparidad sustancial entre los HIC y los LMIC en el numero de ensayos neuroquirurgicos publicados. Un esfuerzo concertado para invertir en el desarrollo de la capacidad de investigacion en los PIBM es un paso esencial para garantizar que se generen pruebas de alta calidad especificas del contexto y de los recursos.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.

Worldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening. In March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs. Drawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs. Lessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.

Background The lack of access to essential surgical care in low-income countries is aggravated by emigration of locally-trained surgical specialists to more affluent regions. Yet, the global diaspora of surgeons, obstetricians, and anesthesiologists from low-income and middle-income countries has never been fully described and compared with those who have remained in their country of origin. It is also unclear whether the surgical workforce is more affected by international migration than other medical specialists. In this study, we aimed to quantify the proportion of surgical specialists originating from low-income and middle-income countries that currently work in high-income countries. Methods We retrieved surgical workforce data from 48 high-income countries and 102 low-income and middle-income countries using the database of the World Health Organization Global Surgical Workforce. We then compared this domestic workforce with more granular data on the country of initial medical qualification of all surgeons, anesthesiologists, and obstetricians made available for 14 selected high-income countries to calculate the proportion of surgical specialists working abroad. Results We identified 1,118,804 specialist surgeons, anesthesiologists, or obstetricians from 102 low-income and middle-income countries, of whom 33,021 (3.0%) worked in the 14 included high-income countries. The proportion of surgical specialists abroad was greatest for the African and South East Asian regions (12.8% and 12.1%). The proportion of specialists abroad was not greater for surgeons, anesthesiologists, or obstetricians than for physicians and other medical specialists (P = .465). Overall, the countries with the lowest remaining density of surgical specialists were also the countries from which the largest proportion of graduates were now working in high-income countries (P = .011). Conclusion A substantial proportion of all surgeons, anesthesiologists, and obstetricians from low-income and middle-income countries currently work in high-income countries. In addition to decreasing migration from areas of surgical need, innovative strategies to retain and strengthen the surgical workforce could involve engaging this large international pool of surgical specialists and instructors.

To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan.Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1-92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression.Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1-30 days of age: 31-60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31-3.15; 61-92 days: aOR: 2.14; 95% CI: 1.13-4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant).Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger.Procéder à un examen rétrospectif des résultats d'un programme de circoncision des nourrissons mené par des professionnels de santé au Pakistan.En nous fondant sur les directives de l'OMS, nous avons formé des techniciens en chirurgie et des sages-femmes afin qu'ils puissent opérer des circoncisions à l'aide du dispositif Plastibell dans deux établissements Indus Health Network. Les outils du programme comprennent un manuel de formation destiné aux professionnels de santé, des brochures d'information pour les familles, un formulaire d'inscription ainsi que des formulaires standardisés pour documenter les détails et résultats de la procédure. Seuls les nourrissons âgés de 1 à 92 jours ont été pris en compte dans cette étude. Les professionnels de santé ont contacté les familles le 1Entre août 2016 et août 2018, 2822 nourrissons circoncis âgés en moyenne de 22,8 jours répondaient aux conditions de participation à l'étude. Parmi eux, 2617 nourrissons (92,7%) ont fait l'objet d'un suivi par le biais d'entretiens téléphoniques de la part des soignants. Les nourrissons plus âgés étaient davantage susceptibles d'éprouver des effets indésirables que ceux circoncis entre 1 et 30 jours: 31–60 jours: odds ratio ajusté, ORA: 2,03; intervalle de confiance de 95%, IC: 1,31–3,15; 61–92 jours: ORA: 2,14; IC de 95%: 1,13-4,05. Les effets indésirables mineurs (100 nourrissons; 3,8%) incluaient l'échec de la séparation du gland (90 nourrissons) et des saignements limités (10 nourrissons). Les effets indésirables majeurs (huit nourrissons; 0,3%) incluaient des saignements nécessitant une intervention (quatre nourrissons), une infection (trois nourrissons) et une déchirure cutanée (un nourrisson).Des protocoles de formation standardisés ainsi qu'une surveillance étroite ont permis aux professionnels de santé autres que des médecins d'effectuer en toute sécurité des circoncisions sur des nourrissons âgés de maximum trois mois.Revisar retrospectivamente los resultados de un programa de circuncisión infantil temprana dirigido por proveedores sanitarios en Pakistán.Según las directrices de la OMS, hemos formado a técnicos quirúrgicos y matronas para que realizaran circuncisiones con el dispositivo Plastibell en dos centros de la Red de Salud Indus. Las herramientas del programa incluyen un manual de formación para los proveedores sanitarios, folletos informativos para las familias, un formulario de inscripción y formularios estandarizados para documentar los detalles del procedimiento y los resultados. Los lactantes de 1 a 92 días de edad eran elegibles para el estudio. Los trabajadores sanitarios se pusieron en contacto con las familias los días 1 y 7 después del procedimiento para registrar cualquier acontecimiento adverso. Se compararon las características de los lactantes que experimentaron acontecimientos adversos con las de los lactantes que no sufrieron complicaciones mediante una regresión logística multivariante.Entre agosto de 2016 y agosto de 2018, 2.822 bebés circuncidados con una media de edad de 22,8 días cumplieron los requisitos para participar en el estudio. De ellos, 2617 lactantes (92,7%) fueron objeto de seguimiento mediante entrevistas telefónicas por parte de los cuidadores. Los lactantes de más edad tuvieron más probabilidades de sufrir acontecimientos adversos que los circuncidados entre 1 y 30 días: 31-60 días: odds ratio ajustada, ORA: 2,03; intervalo de confianza del 95%, IC: 1,31-3,15; 61-92 días: ORA: 2,14; IC del 95%: 1,13-4,05. Los acontecimientos adversos menores (100 lactantes; 3,8%) incluyeron fallos en la separación del glande (90 lactantes) y hemorragias limitadas (10 lactantes). Los acontecimientos adversos importantes (ocho lactantes; 0,3%) incluyeron hemorragias que requirieron intervención (cuatro lactantes), infección (tres lactantes) y desgarro de la piel (un lactante).Los protocolos de formación estandarizados y la estrecha vigilancia han permitido a los profesionales sanitarios distintos de los médicos realizar con seguridad circuncisiones en bebés de hasta los tres meses de edad.الغرض مراجعة نتائج برنامج الختان المبكر للرضع بأثر رجعي، تحت قيادة مقدم الرعاية الصحية في باكستان. الطريقة بناءً على إرشادات منظمة الصحة العالمية (WHO)، قمنا بتدريب فنيي الجراحة والقابلات لإجراء عمليات الختان باستخدام جهاز Plastibell في اثنين من مرافق شبكة Indus الصحية. تتضمن أدوات البرنامج كتيبًا تدريبيًا لمقدمي الرعاية الصحية، ونشرات المعلومات للعائلات، واستمارة تسجيل، واستمارات قياسية لتوثيق تفاصيل ونتائج العملية. كان الرضع من عمر 1 إلى 92 يومًا، مؤهلين للدراسة. قام العاملون الصحيون بالاتصال بالأسر في اليومين الأول والسابع بعد العملية لتسجيل أي أحداث سلبية. قمنا بمقارنة خصائص الرضع الذين يمرون بالأحداث السلبية، مع الرضع الذين لا يواجهون أية مضاعفات باستخدام التحوف اللوجستي متعدد المتغيرات. النتائج ما بين أغسطس/آب 2016 وأغسطس/آب 2018، كان 2822 من الرضع الذكور المختونين بمتوسط ​​عمر 22.8 يومًا، مؤهلين للدراسة. ومن بينهم، تمت متابعة 2617 رضيعًا (92.7%) عن طريق المقابلات الهاتفية مع القائمين على رعايتهم. كان الرضع الأكبر سنًا أكثر عرضة للتعرض لأحداث سلبية، من الأطفال المختونين بعمر 1 إلى 30 يومًا: 31 إلى 60 يومًا: نسبة الاحتمالات المعدلة، نسبة الأرجحية: 2.03؛ فاصل الثقة 95%: 1.31 إلى 3.15 يومًا؛ 61 إلى 92 يومًا: نسبة الاحتمالات المعدلة: 2.14؛ ‏بفاصل ثقة 95%: 1.13 إلى 4.05. تضمنت الأحداث السلبية الطفيفة (100 رضيع؛ 3.8%)، وشملت فشل الجرس في السقوط (90 رضيعًا)، ونزيفًا بسيطًا (10 أطفال). تضمنت الأحداث السلبية الرئيسية (ثمانية أطفال؛ 0.3%) النزيف الذي يتطلب تدخلاً (أربعة أطفال)، والعدوى (ثلاثة أطفال)، وتمزق الجلد (رضيع واحد). الاستنتاج إن بروتوكولات التدريب القياسية والمراقبة عن كثب، أتاحت لمقدمي الرعاية الصحية من غير الأطباء، إجراء عمليات ختان آمنة للرضع من عمر ثلاثة أشهر أو أقل.旨在回顾性地分析由医疗护理提供者主导的巴基斯坦早期婴儿包皮环切术计划的结果。.根据 WHO 的指导方针，我们在两个印度河卫生网络机构培训了一些外科技术人员和助产士，以确保其能够使用塑料钟环切器实施包皮环切术。该计划所采用的工具包括医疗护理提供者培训手册、家庭信息手册、登记表以及详细记录手术程序和手术结果的标准化表格。出生 1-92 天的婴儿符合本项研究的参与条件。医护工作者在术后第 1 天和第 7 天与家属联系，以记录任何不良事件。我们使用多元逻辑回归法比较了出现不良事件的婴儿与未出现并发症的婴儿的特征。.在 2016 年 8 月至 2018 年 8 月期间接受了包皮环切术的 2822 名平均年龄为 22.8 天的男婴符合本次研究的参与条件。看护人员对其中 2617 名婴儿 (92.7%) 进行了电话随访。与在出生 1-30 天内接受包皮环切术的婴儿相比，越大的婴儿越容易发生不良事件：31-60 天：调整后优势比，aOR：2.03；95% 置信区间，CI：1.31–3.15；61–92 天：aOR：2.14；95% CI：1.13-4.05。轻微不良事件（100 名婴儿；3.8%）包括塑料钟未脱落（90 名婴儿）和轻微出血（10 名婴儿）。严重不良事件（8 名婴儿；0.3%）包括需要干预的出血（4 名婴儿）、感染（3 名婴儿）和皮肤撕脱伤（1 名婴儿）。.标准化培训方案和严密监护使得并非医生的医疗护理提供者也能为 3 个月或更小的婴儿安全地实施包皮环切术。.Выполнить ретроспективный обзор результатов программы раннего обрезания крайней плоти у младенцев мужского пола в Пакистане, проводимой провайдерами в сфере медико-санитарных услуг.Основываясь на рекомендациях ВОЗ, мы обучили фельдшеров хирургического отделения и акушерок выполнять обрезание крайней плоти с помощью устройства Plastibell в двух учреждениях сети Indus Health Network. Инструменты программы включают учебное пособие для провайдеров в сфере медико-санитарных услуг, информационные буклеты для семей, регистрационную форму и стандартные формы для документирования сведений о процедуре и результатах. Для исследования подходили младенцы в возрасте от 1 до 92 дней. Работники здравоохранения связывались с семьями на 1-й и 7-й дни после процедуры, чтобы зарегистрировать любые нежелательные явления. Мы сравнили характеристики младенцев, у которых возникли нежелательные явления, с младенцами, у которых не возникло осложнений, с использованием множественной логистической регрессии.За период с августа 2016 года по август 2018 года 2822 обрезанных младенца мужского пола со средним возрастом 22,8 дня соответствовали критериям участия в исследовании. Из них для 2617 младенцев (92,7%) осуществлялся контроль в виде телефонных собеседований с опекунами. У младенцев старшего возраста вероятность возникновения нежелательных явлений выше, чем у младенцев, обрезанных в возрасте от 1 до 30 дней: в возрасте 31–60 дней скорректированное отношение шансов, сОШ: 2,03; 95%-й ДИ: 1,31–3,15; 61–92 дня: сОШ: 2,14; 95%-й ДИ: 1,13–4,05. Незначительные нежелательные явления (100 младенцев; 3,8%) включали неотделившуюся чашу устройства (90 младенцев) и минимальное кровотечение (10 младенцев). Основные нежелательные явления (восемь младенцев; 0,3%) включали кровотечение, которое потребовало вмешательства (четыре младенца), инфекцию (три младенца) и разрыв кожи (один младенец).Стандартизованные протоколы обучения и тщательный мониторинг позволили провайдерам медико-санитарных услуг, которые не являются врачами, выполнять безопасное обрезание крайней плоти у младенцев в возрасте трех месяцев и младше.

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a non-profit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.Identifier les lacunes présentes dans les directives nationales de prise en charge des accidents vasculaires cérébraux (AVC), ainsi que la manière de les combler afin d'améliorer la qualité des soins dans les pays à faible et moyen revenu.Nous avons analysé systématiquement une série de bases de données médicales et sites Internet de sociétés médicales. Nous avons également contacté des organismes internationaux. Toutes les directives nationales de prévention et de prise en charge des AVC, publiées dans n'importe quelle langue entre 2010 et 2020, étaient admises dans cette analyse. Nous avons examiné chaque directive incluse à la recherche de quatre composants clés de la prise en charge des AVC (surveillance, prévention, soins intensifs et rééducation). Enfin, nous avons évalué le degré de conformité avec les huit standards de l'Institut de médecine pour les directives de pratique clinique, mais aussi la facilité avec laquelle ces directives étaient appliquées et la manière dont elles étaient censées être diffusées auprès du public cible.Nous avons étudié 108 directives retenues provenant de 47 pays dont quatre à faible revenu, 24 à moyen revenu et 19 à haut revenu. Globalement, le nombre de directives concernant la prévention primaire des AVC était moins élevé que d'autres volets de soins, et aucune ne recommandait une surveillance. Les directives relatives aux AVC dans les pays à faible et moyen revenu ne répondaient pas aux exigences en matière de développement des directives; d'étendue du public cible; d'intégration des quatre composants de prise en charge des AVC; ni d'adaptation au contexte socioéconomique. La transparence des directives nationales était moins souvent assurée dans les pays à faible et moyen revenu que dans les pays à haut revenu. Moins d'un quart des directives comportaient des plans de mise en œuvre détaillés et des considérations économiques.Les directives relatives à la prise en charge des AVC dans les pays à faible et moyen revenu doivent être renforcées avec le concours d'une plus large catégorie de prestataires et d'acteurs du secteur de la santé. Elles doivent en outre prévoir une gamme complète d'interventions transposables sur le terrain et adaptées au contexte.Identificar las lagunas en las directrices nacionales sobre accidentes cerebrovasculares que podrían subsanarse para mejorar la calidad de los servicios de atención a los accidentes cerebrovasculares en los países con ingresos bajos y medios.Se realizaron búsquedas sistemáticas en bases de datos médicas y sitios web de sociedades médicas y se contactó con organizaciones internacionales. Se incluyeron las directrices específicas de cada país sobre la atención y el control de los accidentes cerebrovasculares en cualquier idioma, publicadas entre 2010 y 2020. Se revisó cada directriz incluida para la cobertura de cuatro componentes clave de los servicios por ataques cerebrovasculares (vigilancia, prevención, atención aguda y rehabilitación). También se evaluó el cumplimiento de los ocho estándares del Instituto de Medicina para las guías de práctica clínica, la facilidad de implementación de las directrices y los planes de difusión al público objetivo.Se revisaron 108 directrices elegibles de 47 países, incluyendo cuatro de bajos ingresos, 24 de medianos ingresos y 19 de altos ingresos. Globalmente, la prevención primaria de los ataques cerebrovasculares estaba cubierta en menos directrices que otros componentes de la atención médica, y ninguna recomendaba la vigilancia. Las directrices sobre ataques cerebrovasculares en los países de ingresos bajos y medios no cumplían con los estándares requeridos para el desarrollo de directrices; la amplitud del público objetivo; la cobertura de los cuatro componentes de los servicios de ataques cerebrovasculares; ni la adaptación al contexto socioeconómico. El número de directrices de los países de ingresos bajos y medios que demostraron ser transparentes fue menor que el de los países de ingresos altos. Menos de una cuarta parte de las directrices incluían planes de aplicación detallados y consideraciones socioeconómicas.Las directrices sobre los ataques cerebrovasculares en los países de ingresos bajos y medios deben elaborarse en colaboración con una categoría más amplia de proveedores de servicios sanitarios y partes interesadas, con un espectro completo de intervenciones traducibles y adecuadas al contexto.تحديد الفجوات في المبادئ التوجيهية الوطنية للسكتة الدماغية التي يمكن سدها لتحسين جودة خدمات رعاية السكتة الدماغية في البلدان منخفضة الدخل والبلدان متوسطة الدخل.قمنا بإجراء البحث بشكل منهجي في قواعد البيانات الطبية والمواقع الإلكترونية للجمعيات الطبية، واتصلنا بالمنظمات الدولية. إن المبادئ التوجيهية الخاصة بكل بلد حول رعاية السكتة الدماغية والسيطرة عليها، بأية لغة منشورة في الفترة من 2010 إلى 2020، كانت مؤهلة ليتم تضمينها. قمنا بمراجعة كل مبدأ توجيهي متضمن لتغطية أربعة مكونات رئيسية لخدمات السكتة الدماغية (المراقبة، والوقاية، والرعاية الدقيقة، وإعادة التأهيل). كما قمنا بتقييم الامتثال لمعايير معهد الطب الثمانية للمبادئ التوجيهية للممارسة الإكلينيكية، وسهولة تنفيذ المبادئ التوجيهية، وخطط النشر بين الجماهير المستهدفة.قمنا بمراجعة 108 من المبادئ التوجيهية المؤهلة من 47 بلدًا، بما في ذلك أربعة بلدان منخفضة الدخل، و24 بلدًا متوسط الدخل، و19 بلدًا مرتفع الدخل. على الصعيد العالمي، غطى القليل من المبادئ التوجيهية الوقاية الأولية من السكتة الدماغية، مقارنةً بمكونات الرعاية الأخرى، مع عدم توصية أي منها بالمراقبة. كانت المبادئ التوجيهية حول السكتة الدماغية في البلدان منخفضة الدخل والبلدان متوسطة الدخل أقل من المعايير المطلوبة لتطوير المبادئ التوجيهية؛ وقاعدة الجمهور المستهدف؛ وتغطية المكونات الأربعة لخدمات السكتة الدماغية؛ والتكيف مع السياق الاجتماعي والاقتصادي. عدد المبادئ التوجيهية للبلدان منخفضة الدخل ومتوسطة الدخل التي أظهرت الشفافية أقل من المبادئ التوجيهية من البلدان ذات الدخل المرتفع. اشتمل أقل من ربع المبادئ التوجيهية على خطط تفصيلية للتنفيذ والاعتبارات الاجتماعية الاقتصادية.إن المبادئ التوجيهية حول السكتة الدماغية في البلدان ذات الدخل المنخفض، والبلدان ذات الدخل المتوسط، تحتاج إلى تطويرها بالاشتراك مع فئة أكبر من مقدمي الرعاية الصحية وأصحاب المصلحة، مع نطاق كامل من التدخلات القابلة للتفسير والملائمة للسياق.旨在确定国家中风指南存在的差距，并对这些差距加以弥补以增强中低收入国家中风护理服务的质量。.我们系统性地检索了医学数据库和医学会网站，并联系了国际组织。自 2010 年至 2020 年以任何语言发表的针对特定国家的中风护理和控制指南均满足纳入资格。我们回顾了各个指南所涵盖的中风服务四大关键要素（监测、预防、紧急护理和康复）。我们还评估了医学研究所八项临床实践指南标准的遵守情况，指南实施的难易程度以及出于目标群体宣传目的而制定的计划。.我们回顾了来自 47 个国家（其中包括 4 个低收入国家、24 个中等收入国家和 19 个高收入国家）的 108 份符合条件的指南。整体而言，与其他护理要素相比，涵盖初级中风预防的指南较少，且没有指南针对监测给出建议。低收入和中等收入国家的中风指南在以下方面低于指南制定所需达到的标准：目标受众的广度、涵盖中风服务的四大要素以及对社会经济环境的适应程度。与高收入国家的指南相比，低收入和中等收入国家的指南透明度较低。不到四分之一的指南涵盖详细的实施计划和社会经济学方面的考虑因素。.低收入和中等收入国家的中风指南需要与更广泛的医疗护理提供者以及利益相关者共同制定，并因地制宜地采取一系列可转化的干预调控措施。.Выявить пробелы в национальных рекомендациях по инсульту, которые возможно устранить с целью повышения качества услуг по лечению инсульта в странах с низким и средним уровнем доходов.Авторы систематически проводили поиск в медицинских базах данных и на веб-сайтах медицинских обществ, а также связывались с международными организациями. Национальные рекомендации по лечению и контролю инсульта, опубликованные с 2010 по 2020 г. на любом языке, соответствовали критериям для включения. Авторы изучили каждую включенную рекомендацию в отношении охвата четырьмя ключевыми компонентами услуг по инсульту (эпиднадзор, профилактика, неотложная помощь и реабилитация). Было также оценено соответствие восьми стандартам Института медицины для рекомендаций по клинической практике, простота внедрения рекомендаций и планы по их распространению среди целевых аудиторий.Авторы изучили 108 подходящих рекомендаций из 47 стран, включая четыре страны с низким уровнем доходов, 24 страны со средним уровнем доходов и 19 стран с высоким уровнем доходов. Во всем мире первичная профилактика инсульта охватывала меньшее количество рекомендаций по сравнению с другими компонентами медицинской помощи, и ни один из них не рекомендовал эпиднадзор. Рекомендации по инсульту в странах с низким и средним уровнем доходов не соответствовали требуемым стандартам для разработки рекомендаций, широте целевой аудитории, охвату четырьмя компонентами услуг по инсульту и адаптации к социально-экономическим условиям. Рекомендации, принятые в странах с низким и средним уровнем доходов, в меньшей степени демонстрировали прозрачность, в отличие от рекомендаций для стран с высоким уровнем дохода. Менее четверти рекомендаций включали подробные планы по реализации и социально-экономические соображения.Рекомендации по инсульту в странах с низким и средним уровнем доходов необходимо разрабатывать совместно с более широкой категорией поставщиков медицинских услуг и заинтересованных сторон, с полным спектром реализуемых и соответствующих обстановке вмешательств.

Background: Uganda is a low-income country with blended, tiered government health care facilities and private/non-governmental (NGO)/mission hospitals. The population is 84% rural; 100% of referral hospitals and majority of specialist physicians are urban. Summary of background data: This project compared various levels of government hospitals with private/NGO hospitals to determine adequacy to deliver emergency and essential surgical care (EESC) and anesthesia. Methods: Using the WHO Situational Analysis Tool, a representative selection of 38 hospitals (25% of Ugandan hospitals) was assessed for capacity to deliver surgical, anesthetic and obstetric care in 4 domains: infrastructure, human resources, surgeries performed or referred, and equipment. Results: In all facilities, laboratory availability was 86%; anesthesia machines, 66%; generators, 55%; and continuous running water, 42%; oxygen, 32%; and electricity, 26%. Resuscitator bags and mask/tubing were present less than 50% of health facilities. Only 84% of all health facilities had a stethoscope; sterilizers only at 50%. This situation was much more dismal in district hospitals. Surgeons were found at 71% of public hospitals and 63% of NGO/mission hospitals; 60% surgeons, and over 50% of anesthesiologists were only in teaching hospitals; obstetricians almost exclusively in higher-level hospitals. Conclusions: The infrastructure for surgical services and anesthesia were noticeably absent at district hospital level and below, yet were readily available at the tertiary care center level. Overall national and regional referral hospitals were better equipped than NGO facilities, suggesting the government is capable of fully equipping hospitals to provide surgical care. These surveys highlight potential for improvement in surgical care at all levels.

Global neurosurgery is the practice of neurosurgery with the primary purpose of delivering timely, safe, and affordable neurosurgical care to all who need it. This field is led by neurosurgeons, and global neurosurgery sessions are now part of every major international neurosurgical meeting. The World Federation of Neurosurgical Societies (WFNS) is working to coordinate activities and align all related activities for greater impact. This report updates the contributions made by the WFNS-WHO Liaison Committee at the most recent World Health Assembly (WHA) in 2019. The WHA is a decision-making body of the World Health Organization (WHO), attended by its 194 Member States. The WFNS has maintained official relations as a nongovernmental organization with the WHO for over 30 years, and this year 15 neurosurgical delegates attended events during the WHA. Participation by neurosurgeons continues to grow as many WHA events focused on global surgery have intrinsically involved neurosurgical leadership and participation. This year, resolution WHA72.31, entitled “Emergency and trauma care, Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured,” was passed. This resolution provides further opportunities for neurosurgical advocacy as the landscape of global surgery gains recognition and momentum.

Background Burns are a leading cause of global disease burden, with children in low- and middle-income countries (LMICs) disproportionately affected. Effective management improves outcomes; however, the availability of necessary resources in LMICs remains unclear. We evaluated surgical centres in LMICs using the WHO Surgical Assessment Tool (SAT) to identify opportunities to optimize paediatric burn care. Methods We reviewed WHO SAT database entries for 2010–2015. A total of 1121 facilities from 57 countries met the inclusion criteria: facilities with surgical capacity in LMICs operating on children. Human resources, equipment and infrastructure relevant to paediatric burn care were analysed by WHO Regional and World Bank Income Classifications and facility type. Results Facilities had an average of 147 beds and performed 485 paediatric operations annually. Discrepancies existed between procedures performed and resource availability; 86% of facilities performed acute burn care, but only 37% could consistently provide intravenous fluids. Many, particularly tertiary, centres performed contracture release and skin grafting (41%) and amputation (50%). Conclusions LMICs have limited resources to provide paediatric burn care but widely perform many interventions necessary to address the burden of burns. The SAT may not capture innovative and traditional approaches to burn care. There remains an opportunity to improve paediatric burn care globally.

Background Many health care facilities in low- and middle-income countries are inadequately resourced. COVID-19 has the potential to decimate surgical health care services unless health systems take stringent measures to protect health care workers from viral exposure and ensure the continuity of specialized care for patients. Among these measures, the timely diagnosis of COVID-19 is paramount to ensure the use of protective measures and isolation of patients to prevent transmission to health care personnel caring for patients with an unknown COVID-19 status or contact during the pandemic. Besides molecular and antibody tests, chest computed tomography (CT) has been assessed as a potential tool to aid in the screening or diagnosis of COVID-19 and could be valuable in the emergency care setting. Objective This paper presents the protocol for an umbrella review that aims to identify and summarize the available literature on the diagnostic accuracy of chest CT for COVID-19 in trauma surgery patients requiring urgent care. The objective is to inform future recommendations on emergency care for this category of patients. Methods We will conduct several searches in the L·OVE (Living Overview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials, and over 30 other sources. The search results will be presented according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis). This review will preferentially consider systematic reviews of diagnostic test accuracy studies, as well as individual studies of such design, if not included in the systematic reviews, that assessed the sensitivity and specificity of chest CT in emergency trauma surgery patients. Critical appraisal of the included studies for risk of bias will be conducted. Data will be extracted using a standardized data extraction tool. Findings will be summarized narratively, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be used to grade the certainty of evidence. Results Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in October 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish the findings in a peer-reviewed journal and present our results at conferences that engage the most pertinent stakeholders. Conclusions During the COVID-19 pandemic, protecting health care workers from infection is essential. Up-to-date information on the efficacy of diagnostic tests for detecting COVID-19 is essential. This review will serve an important role as a thorough summary to inform evidence-based recommendations on establishing effective policy and clinical guideline recommendations. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020198267; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=198267 International Registered Report Identifier (IRRID) PRR1-10.2196/25207

info:eu-repo/semantics/published

Background On September 25, 2015, the United Nations General Assembly adopted a 17-goal action plan to transform the world by the year 2030, ushering in the Era of Sustainable Development. These Sustainable Development Goals (SDGs) were designed to continue where the preceding Millennium Development Goals left off, expanding on the Millennium Development Goal successes, and facing the challenges encountered during the previous decade and a half. The current Era of Sustainable Development and its impact on a breadth of neurosurgical concerns provide several unprecedented opportunities to enhance political prioritization of neurosurgical care equity. Neurosurgeons could therefore be well positioned to participate in the leadership of these global health development and policy reform efforts. Methods Each of the 17 SDGs was reviewed and analyzed for its relevance to the public health aspects of neurosurgery. The analysis was guided by a review of the literature performed in PubMed, Google Scholar, and the databases of the World Health Organization. Results Among the 17 SDGs, 14 were found to be of direct or indirect relevance to neurosurgeons and neurosurgical care delivery. Results of this analysis are presented and discussed, and recommendations are provided for using this knowledge to inform the emerging discipline of global neurosurgery. Conclusions This article contributes to the global neurosurgery movement by providing the socially and globally conscious neurosurgeon with a compass for directing the place of neurosurgery in the international agenda for sustainable development.

OBJECTIVEThe global magnitude of neurosurgical disease is unknown. The authors sought to estimate the surgical and consultative proportion of diseases commonly encountered by neurosurgeons, as well as surgeon case volume and perceived workload.METHODSAn electronic survey was sent to 193 neurosurgeons previously identified via a global surgeon mapping initiative. The survey consisted of three sections aimed at quantifying surgical incidence of neurological disease, consultation incidence, and surgeon demographic data. Surgeons were asked to estimate the proportion of 11 neurological disorders that, in an ideal world, would indicate either neurosurgical operation or neurosurgical consultation. Respondent surgeons indicated their confidence level in each estimate. Demographic and surgical practice characteristics—including case volume and perceived workload—were also captured.RESULTSEighty-five neurosurgeons from 57 countries, representing all WHO regions and World Bank income levels, completed the survey. Neurological conditions estimated to warrant neurosurgical consultation with the highest frequency were brain tumors (96%), spinal tumors (95%), hydrocephalus (94%), and neural tube defects (92%), whereas stroke (54%), central nervous system infection (58%), and epilepsy (40%) carried the lowest frequency. Similarly, surgery was deemed necessary for an average of 88% cases of hydrocephalus, 82% of spinal tumors and neural tube defects, and 78% of brain tumors. Degenerative spine disease (42%), stroke (31%), and epilepsy (24%) were found to warrant surgical intervention less frequently. Confidence levels were consistently high among respondents (lower quartile > 70/100 for 90% of questions), and estimates did not vary significantly across WHO regions or among income levels. Surgeons reported performing a mean of 245 cases annually (median 190). On a 100-point scale indicating a surgeon’s perceived workload (0—not busy, 100—overworked), respondents selected a mean workload of 75 (median 79).CONCLUSIONSWith a high level of confidence and strong concordance, neurosurgeons estimated that the vast majority of patients with central nervous system tumors, hydrocephalus, or neural tube defects mandate neurosurgical involvement. A significant proportion of other common neurological diseases, such as traumatic brain and spinal injury, vascular anomalies, and degenerative spine disease, demand the attention of a neurosurgeon—whether via operative intervention or expert counsel. These estimates facilitate measurement of the expected annual volume of neurosurgical disease globally.

Since the creation of the World Health Organization (WHO) in 1948, the annual World Health Assembly (WHA) has been the major forum for discussion, debate, and approval of the global health agenda. As such, it informs the framework for the policies and budgets of many of its Member States. For most of its history, a significant portion of the attention of health ministers and Member States has been given to issues of clean water, vaccination, and communicable diseases. For neurosurgeons, the adoption of WHA Resolution 68.15 changed the global health landscape because the importance of surgical care for universal health coverage was highlighted in the document. This resolution was adopted in 2015, shortly after the publication of The Lancet Commission on Global Surgery Report titled “Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development.” Mandating global strengthening of emergency and essential surgical care and anesthesia, this resolution has led to the formation of surgical and anesthesia collaborations that center on WHO and can be facilitated via the WHA. Participation by neurosurgeons has grown dramatically, in part due to the official relations between WHO and the World Federation of Neurosurgical Societies, with the result that global neurosurgery is gaining momentum.

Noncommunicable diseases (NCDs), including stroke and heart attacks, the largest causes of mortality worldwide, are now firmly on the global agenda through the United Nations 2030 Sustainable Development Agenda. There are several important initiatives underway to address the burden of stroke worldwide and to contribute to the Sustainable Development Goals (SDGs) of reducing premature mortality from NCDs by one third by 2030 (SDG 3.4). In May 2017, the 70th World Health Assembly sets out the preparation for the third high-level meeting of the United Nations General Assembly on the prevention and control of NCDs, to be held at the United Nations in September 2018. The resolution on this item urged member states to continue to implement related resolutions and commitments. The Assembly also endorsed an updated Appendix 3 of the WHO Global Action Plan on NCDs—a set of cost-effective and other recommended interventions to prevent …

Background An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit. Objective To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services. Methods A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care. Results 68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. Conclusions There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Objective\ud \ud Evaluate the capacity of government-run hospitals in Bangladesh to provide emergency and essential surgical, obstetric and anaesthetic services.\ud \ud Methods\ud \ud Cross-sectional survey of 240 Bangladeshi Government healthcare facilities using the World Health Organisation Situational Analysis Tool to Assess Emergency and Essential Surgical Care (SAT). This tool evaluates the ability of a healthcare facility to provide basic surgical, obstetric and anaesthetic care based on 108 queries that detail the infrastructure and population demographics, human resources, surgical interventions and reason for referral, and available surgical equipment and supplies. For this survey, the Bangladeshi Ministry of Health sent the SAT to sub-district, district/general and teaching hospitals throughout the country in April 2013.\ud \ud Results\ud \ud Responses were received from 240 healthcare facilities (49.5% response rate): 218 sub-district and 22 district/general hospitals. At the sub-district level, caesarean section was offered by 55% of facilities, laparotomy by 7% and open fracture repair by 8%. At the district/general hospital level, 95% offered caesarean section, 86% offered laparotomy and 77% offered open fracture treatment. Availability of anaesthesia services, general equipment and supplies reflected this trend, where district/general hospitals were better equipped than sub-district hospitals, though equipment and infrastructure shortages persist.\ud \ud Conclusion\ud \ud There has been overall impressive progress by the Bangladeshi Government in providing essential surgical services. Areas for improvement remain across all key areas, including infrastructure, human resources, surgical interventions offered and available equipment. Investment in surgical services offers a cost-effective opportunity to continue to improve the health of the Bangladeshi population and move the country towards universal healthcare coverage.

Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability.' Stroke, the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is lost by blockage or rupture of an artery to the brain, is also a leading cause of dementia and depression. (2) Globally, 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years occur in low- and middle-income countries. (3-5) Over the last four decades, the stroke incidence in low- and middle-income countries has more than doubled. During these decades stroke incidence has declined by 42% in high-income countries. 3 On average, stroke occurs 15 years earlier in--and causes more deaths of people living in low--and middle-income countries, when compared to those in high-income countries. (2) Strokes mainly affect individuals at the peak of their productive life. Despite its enormous impact on countries' socio-economic development, this growing crisis has received very little attention to date. The risk factors for stroke are similar to those for coronary heart disease and other vascular diseases. Effective prevention strategies include targeting the key modifiable factors: hypertension, elevated lipids and diabetes. Risks due to lifestyle factors can also be addressed: smoking, low physical activity levels, unhealthy diet and abdominal obesity. (6) Combinations of such prevention strategies have proved effective in reducing stroke mortality even in some low-income settings. (7,8) Furthermore, as most guidelines are based on high-income country data, uncertainty remains regarding best management of stroke of unknown type in low- and middle-income countries. For example, in low- and middle-income countries, 34% of strokes (versus 9% in high-income countries) are of haemorrhagic subtype and up to 84% of stroke patients in low- and middle-income countries (versus 16% in high income countries) die within three years of diagnosis. (2) Current guidelines for the management of acute stroke recommend a course of treatment based on the diagnosis of ischaemic stroke (versus haemorrhagic stroke) made using computed tomography (CT) scanners. In low-resource settings, CT scanners are either unavailable or unaffordable, forcing clinicians to make difficult clinical decisions, such as whether to anticoagulate patients or not, and to what level to control their blood pressure without a means of distinguishing between ischaemic and haemorrhagic stroke. These patient management challenges, combined with inadequate rehabilitation services, lack of preventive measures, as well as poor understanding of the possible unique risk factors associated with stroke in low- and middle-income countries, may account for the disproportionately large stroke burden borne by these countries. The reasons for the younger age of onset, higher rates of haemorrhagic subtype and higher case fatality, are unknown. …

Purpose To evaluate the efficacy of fractionated proton radiotherapy for a population of patients with benign cavernous sinus meningiomas. Methods and Materials Between 1991 and 2002, 72 patients were treated at Loma Linda University Medical Center with proton therapy for cavernous sinus meningiomas. Fifty-one patients had biopsy or subtotal resection; 47 had World Health Organization grade 1 pathology. Twenty-one patients had no histologic verification. Twenty-two patients received primary proton therapy; 30 had 1 previous surgery; 20 had more than 1 surgery. The mean gross tumor volume was 27.6 cm 3 ; mean clinical target volume was 52.9 cm 3 . Median total doses for patients with and without histologic verification were 59 and 57 Gy, respectively. Mean and median follow-up periods were 74 months. Results The overall 5-year actuarial control rate was 96%; the control rate was 99% in patients with grade 1 or absent histologic findings and 50% for those with atypical histology. All 21 patients who did not have histologic verification and 46 of 47 patients with histologic confirmation of grade 1 tumor demonstrated disease control at 5 years. Control rates for patients without previous surgery, 1 surgery, and 2 or more surgeries were 95%, 96%, and 95%, respectively. Conclusions Fractionated proton radiotherapy for grade 1 cavernous sinus meningiomas achieves excellent control rates with minimal toxicities, regardless of surgical intervention or use of histologic diagnosis. Disease control for large lesions can be achieved by primary fractionated proton therapy.

Summary box Chinese philosopher Laozi wrote, ‘Go to the people. Live among them. Learn from them. Start with what they know. Build on what they have’. This ancient counsel has modern-day application in the little-known development of primary healthcare (PHC) service delivery models and the integration of surgical care and anaesthesia into these models. Currently, five billion people lack access to safe, timely and affordable surgical and anaesthesia care; in low-resource settings, nine of ten people cannot access basic surgical services. Globally, 33 million individuals incur catastrophic expenditures resulting from surgical and anaesthesia care, and this number climbs to 81 million if indirect costs are included.1 The 2030 Agenda for Sustainable Development, approved by …