IntroductionThe Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country’s surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.MethodsWe did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.ResultsWe included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%–27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.ConclusionsEfforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.

Introduction5 billion people around the world do not have access to safe, affordable, timely surgical care. This series of qualitative interviews was launched by The Lancet Commission on Global Surgery (LCoGS) with the aim of understanding the contextual challenges—the specific circumstances—faced by surgical care providers in low-resource settings who care for impoverished patients, and how those providers overcome these challenges.MethodsFrom January 2014 to February 2015, 20 LCoGS collaborators conducted semistructured interviews with 148 surgical providers in low-resource settings in 21 countries. Stratified purposive sampling was used to include both rural and urban providers, and reputational case selection identified individuals. Interviewers were trained with an implementation manual. Following immersion into de-identified texts from completed interviews, topical coding and further analysis of coded texts was completed by an independent analyst with periodic validation from a second analyst.ResultsProviders described substantial financial, geographic and cultural barriers to patient access. Rural surgical teams reported a lack of a trained workforce and insufficient infrastructure, equipment, supplies and banked blood. Urban providers face overcrowding, exacerbated by minimal clinical and administrative support, and limited interhospital care coordination. Many providers across contexts identified national health policies that do not reflect the realities of resource-poor settings. Some findings were region-specific, such as weak patient–provider relationships and unreliable supply chains. In all settings, surgical teams have created workarounds to deliver care despite the challenges.DiscussionWhile some differences exist between countries, the barriers to safe surgery and anaesthesia are overall consistent and resource-dependent. Efforts to advance and expand global surgery must address these commonalities, while local policymakers can tailor responses to key contextual differences.

BackgroundFive billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception.MethodsFrom September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis.ResultsThe Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need.ConclusionBarriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.

Fingertip injuries in children are common and result in significant burden, yet are mostly preventable. Most injuries occur at home in a door or window. Although these patients generally heal well, fingertip injuries pose a health, time, and financial burden. Increased awareness and education may help to avoid these injuries.

Introduction COVID-19 has spread rapidly in the United States since January 2020. Methods We estimated mean epidemic doubling time, an important measure of epidemic growth, nationally, by state and in association with stay-at-home orders. Results Epidemic doubling time in the US was 2.68 days (95%CI:2.30–3.24) prior to widespread mitigation efforts, increasing by 82% to 15 days (95%CI:12.89-17.94) during the mitigation phase. Among states without stay-at-home orders, median increase in doubling time was 34% (95%CI:21.16-68.85) while for states with stay-at-home orders, median increase was 72.9% (95%CI:69.18-76.11). Discussion Statewide mitigation strategies were strongly associated with increased epidemic doubling time.