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In one controlled trial, SMT and sham manipulation were compared in 102 participants with MRI-confirmed LDH; the SMT group showed significantly greater improvement in back and leg pain after 6 months . Nevertheless, the intervention in that study was a combination of soft tissue manipulation and thrust manipulation, and the diagnosis and treatment of SIJ hypomobility were not considered. | study | 99.9 |
In a prospective cohort study, Leemann et al., investigated the effect of high-velocity, low-amplitude SMT in patients with acute or chronic MRI-confirmed LDH, and reported clinically significant improvement in back and leg NRS and ODI scores in both short-term and long-term assessments . In a follow-up study, Ehrler et al., investigated the association of magnetic resonance imaging features, including axial location and type of herniation, with the outcomes of SMT in patients with LDH . This study reported greater improvements in symptoms among patients with sequestrated SLDD who received SMT to the level of herniation. These studies, however, did not consider the treatment of the SIJ in patients with LDH. | review | 99.7 |
Burton et al., also compared SMT with chemonucleolysis in the treatment of patients with SLDD, and reported greater improvements in back pain and disability in the first few weeks in the SMT group . Their SMT, however, included a combination of thrust manipulation, mobilization and soft tissue stretching. | review | 93.1 |
The results of previous studies have shown that SMT is effective in the treatment of LDH . The study most similar to ours is the one by Galm et al., which included 150 patients with LDH, 46 of whom had SIJ dysfunction. All participants received routine physiotherapy, mobilization and SMT in the prone position. Significant improvements were reported in lumbar and ischiatic pain in the SIJ dysfunction group. These authors concluded that in the presence of lumbar and ischiatic symptoms, appropriate treatment for SIJ dysfunction should be considered regardless of intervertebral disc pathomorphology . In this study, however, the number of treatment sessions and the results of SIJ and LDH physical tests were not reported. | study | 99.44 |
Our study had some limitations which should be noted. The pre–post test design did not include a control group; consequently, the results cannot be considered evidence in support of the clinical efficacy of SMT for patients with LDH and SIJ hypomobility. A controlled trial is advisable in which combined manipulations are compared to lumbar or SIJ manipulation separately, to elucidate whether using both lumbar and SIJ manipulation together yields better outcomes than using a single type of manipulation. The small sample size and lack of long-term follow-up are other limitations. In addition, we are aware that measuring physiologic responses to SMT by recording electromyographic activity of the spinal muscles, the myotomes and dermatomes of the involved nerve roots, would strengthen the results of future studies. Also, more reliable tests for SIJ dysfunction are available and should be used in future studies. Despite these limitations, we addressed some shortcomings of previous studies. The strengths of the present study were matching of the physical examination findings with imaging findings, considering SIJ hypomobility in the treatment of patients with LDH, and the application of spinal thrust manipulation alone rather than a combination of therapeutic methods. | study | 99.94 |
Spinal manipulative therapy can potentially improve pain, functional disability and SIJ mobility in patients with LDH concomitant with SIJ hypomobility; therefore, it can be implemented in physical therapy programs for these patients. However, further studies with larger sample sizes, longer follow-up periods and real control groups should be done to provide more accurate results. | other | 99.9 |
Environmental exposures and genetic predisposition are hypothesized to interact to result in the expression of autoimmune rheumatic diseases such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), and systematic autoimmune rheumatic diseases (SARDs) , as well as other immune-mediated diseases such as inflammatory bowel disease and multiple sclerosis . Identifying modifiable risk factors for disease development and prognosis is important to reduce the substantial impact and burden of these chronic diseases in society. | review | 99.8 |
Air pollution is a plausible risk factor for autoimmune disease development. Other inhalants such as tobacco smoke and silica are strongly associated with the development of RA, related to their ability to directly interact with alveolar tissue [4, 5]. Air pollution has been demonstrated to be able to directly stimulate an inflammatory response and indirectly alter the microbiome . A relationship between particulate matter exposure and elevations in inflammatory marker levels has been described [8–11]. As randomized controlled trials to assess directly for causation between air pollutant exposures and disease development in humans are not feasible, we must rely on observational studies to assess for evidence of associations. Fortunately, several methods to estimate air pollutant exposure exist. A variety of air pollutants from industrial and private sources are measurable at fixed-site continuous monitoring stations that collect hourly mean levels of criteria air pollutants, including particulate matter <2.5 μm in size (PM2.5), particulate matter <10 μm in size (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3). The hourly data can then be averaged to obtain defined temporal estimates for the region (e.g., a city). Land use regression models use Geographic Information System (GIS) to estimate air pollutant exposure through a combination of land use, traffic, population density, physical geography, and meteorology across an area and predict concentrations at a defined site, such as an individual's location of residence determined by postal code . Inverse distance weighting (IDW) uses the general principle of interpolation, where values at a site are estimated based on distance from a measured value at another point (e.g., a monitoring station) under the presumption of reducing pollutant levels with increasing distance . Finally, remote sensing through satellite imaging yields estimates across broad geographic areas. | review | 99.7 |
Our objective was to identify studies estimating associations between exposure to the air pollutants listed above and the risk of development of select rheumatic diseases. This included inflammatory arthritis conditions such as RA and JIA, as well as SARDs and individual diseases of autoimmune myositis, systemic lupus erythematosus (SLE), scleroderma, and vasculitis. | study | 99.94 |
MEDLINE (1946 to September 2016) and EMBASE (1980 to 2016, week 37) databases were searched using MeSH terms and keywords for rheumatic diseases (RA, SLE, JIA, inflammatory myositis, scleroderma, vasculitis, and SARDs) in relation to exposure to measured air pollutants (Search Strategy in Appendix). | study | 73.44 |
Three authors (Gavin Sun, Glen Hazlewood, and Cheryl Barnabe) independently completed title and abstract and full-text reviews. Studies were included based on the following criteria: assessing the outcome of a rheumatic disease of interest (RA, JIA, SARDs, and individual diseases of autoimmune myositis, SLE, scleroderma, and vasculitis), individual exposure to ambient air pollutants (PM2.5, PM10, SO2, NO2, CO, and O3), and having a case-control, case cross-over, or cohort design. Only English language studies were included. The study had to report risk estimates (any of relative risk (RR), hazard ratio (HR), or odds ratio (OR)) with the corresponding 95% confidence intervals (95% CI) or sufficient data for calculation. Reviews, case reports, mechanism studies, and nonhuman studies were excluded. | review | 99.9 |
Data extraction was performed in duplicate by two authors (Gavin Sun and Cheryl Barnabe). A standard reporting form was developed to extract pertinent information from each study, including the country or region of study, calendar years of study, diagnosis criteria for the rheumatic disease assessed, and the number of patients in case or control groups in each category. The study design and method of assessing air pollutant levels were also extracted. The estimates and their margin of error were extracted. The Newcastle-Ottawa scale was used to assess the quality of the studies relevant to the objective, again in duplicate by two authors (Gavin Sun and Cheryl Barnabe). For case-control studies, quality was assessed for four domains of selection (case definition, representativeness of cases, selection of controls, and definition of controls), two domains of comparability (study controls for the most important factor and any additional important factor), and three domains of exposure (ascertainment of exposure, same method of ascertainment for cases and controls, and the nonresponse rate). For cohort studies, quality is assessed for four domains of selection (representativeness of exposed cohort, selection of the nonexposed cohort, ascertainment of exposure, and demonstration that the outcome of interest was not present at start of study), two domains of comparability (study controls for the most important factor and any additional important factor), and three domains of outcome (method of assessment of outcome, follow-up period, and adequacy of follow-up of cohorts). Points are assigned based on specified levels of quality within each domain to a maximum of 9 points. | review | 88.94 |
Our a priori study protocol intention was to perform meta-analysis on eligible studies. Following the full-text review stage, we determined that pooling was not appropriate given the small number of studies and heterogeneity in methods; thus the studies were summarized qualitatively. | review | 99.9 |
We identified studies in RA (n = 4), SARDs (n = 2), and JIA (n = 2) populations; no studies were found for SLE, inflammatory myopathies, or scleroderma as unique entities. With the exception of studies from Sweden and Taiwan, all studies were of North American populations. One abstract each in the conditions of ANCA vasculitis and Kawasaki Disease was found, but they did not report risk estimates and thus were not included in the formal synthesis. | review | 99.8 |
Four studies included subjects with RA (two case-control studies [18, 19] and two cohort studies [17, 20]) and examined associations with exposure to NO2, SO2, PM2.5, and PM10 (Table 2). In Hart et al., 2013, using data from the Nurses' Health Study and land use regression models, there was no definite evidence for increased RA risk related to a cumulative average exposure to NO2, SO2, PM10, or PM2.5 after adjustment for covariates . In Hart et al., 2013, using data from the Swedish Epidemiological Investigation of Rheumatoid Arthritis study and land use regression models, the investigators were unable to demonstrate any increased risk for the development of RA with exposure to NO2, PM10, or SO2 . In the study by De Roos et al., RA definitions were based on physician billing and prescription data; land use regression was used in the estimates for PM2.5 and NO2 as well as additional pollutants, black carbon and NO, and the inverse distance weighting method was used for PM10 and SO2 estimates as well as for NO, ozone, and CO . When the RA definition required a specialist-confirmed diagnosis, air pollutant exposure effect estimates were all inversely associated with the development of RA. In this study, residence proximity to roadway was additionally studied as a proxy for air pollutant exposure, with a significantly higher risk for RA for those within 50 metres from a highway compared to those over 150 metres away (OR: 1.37; 95% CI: 1.11 to 1.68). In the study by Chang et al., data from monitoring sites were linked to administrative health data and incident RA cases were studied . No association was found for PM2.5 exposure, but a significantly higher risk of incident RA was found in those exposed to the highest NO2 levels (adjusted HR for 3rd quartile: 1.53; 95% CI: 1.12 to 2.09; adjusted HR for 4th quartile: 1.52; 95% CI: 1.11 to 2.08). | review | 85.8 |
Bernatsky et al. reported the association between PM2.5 exposure and the odds of prevalent SARDs in case-control studies performed in Quebec and Alberta, Canada . Exposure measurement was determined using average residential exposures at diagnosis based on satellite-derived data. In Alberta, a nonlinear association was found. The OR at PM2.5 exposures of 6.02 to 6.92 μg/m3 was 1.25 (95% Credible Interval (CrI): 1.15 to 1.36), the OR at exposures of 6.92 to 8.11 μg/m3 was 1.03 (95% CrI: 0.94 to 1.13), and the OR at exposures of ≥8.12 μg/m3 was 1.13 (95% CrI: 1.02 to 1.25) after adjustment for sex, age, urban versus rural residence, and median income. In Quebec, increasing odds for increasing levels of PM2.5 exposure were demonstrated, with significant odds at levels of ≥11.81 μg/m3. In a study focused on one city in Alberta (Calgary) using land use regression models, exposure to PM2.5 appeared to be potentially associated with prevalent SARD (OR: 1.10; 95% CrI: 1.01 to 1.22) in the model adjusted for sex, mean income, age > 45 years, and interaction between age and sex . No association with NO2 was demonstrated (OR: 1.02; 95% CrI: 0.98 to 1.02) . | study | 99.94 |
Two North American studies have explored the association between PM2.5 and JIA. From a patient population in Utah, 338 cases were identified based on a clinical examination by a rheumatologist. Exposure determination was based on monitoring sites data and no-intercept regression models. RR of 1.60 per 10 μg/m3 (95% CI: 1.00 to 2.54) for disease onset was found for children < 5.5 years of age but the results were imprecise when all ages were included in the analysis (RR: 1.11; 95% CI: 0.85–1.45) . The results were not replicated when studying a broader population in America and Canada with systemic-onset JIA . | study | 99.94 |
The four studies in RA and two studies in SARDs were all deemed to be of high quality on the Newcastle-Ottawa scale in domains of selection, comparability, and exposure in the case-control studies and domains of selection, comparability, and outcome for the cohort study. Both studies in JIA were rated at lower quality, related to the case-crossover design selected. A summary of the quality assessment is found in Tables 3 and 4. | review | 99.75 |
The goal of our research was to synthesize the published literature on associations between air pollution and the development of rheumatic disease. Air pollution has previously been associated with inflammation and other immune-mediated diseases such as inflammatory bowel disease and multiple sclerosis , with the hypothesis built on strong basic science and translational studies [6, 27]. We identified relevant studies in RA, SARDs, and JIA conditions. In a cohort study from the USA and a case-control study from Sweden, no association between an increased RA risk and exposure to NO2, SO2, or PM was detected. In contrast, the cohort study from Taiwan found increased risk of RA with exposure to higher levels of NO2. Surprisingly, the case-control study by De Roos et al. did find an increased risk for RA based on proximity of the primary residence to highways but a potential reduced risk of developing RA in relation to air pollutant exposure , which is counterintuitive. In contrast, exposure to PM2.5 does appear to confer increased risk for SARDs and was a risk factor for JIA in US children below 5.5 years of age. We additionally identified abstracts on ANCA vasculitis and Kawasaki Disease , which reported no association with exposure to PM10 and PM2.5, respectively, although estimates were not provided. | study | 99.6 |
There are several possible reasons for the observed findings. Just as peak incidence of RA varies with age, there may be periods of life where the impact of air pollutants has greater influence on subsequent susceptibility to developing autoimmune diseases. Just as younger patients appeared to be more vulnerable to an association between air pollutants and JIA onset in Zeft et al.'s study , using multivariate analysis controlling for smoking, occupational exposure, home distance to sources of inhaled pollutants, seasonality, and traffic exposure, Orione et al. showed a significant association (odds ratio of 12.2) between carbon monoxide in the third trimester and the subsequent development of juvenile dermatomyositis . Interactions between pollution exposure and specific risk alleles for different autoimmune conditions may also explain the difference in findings of association between air pollutants and different diseases. | review | 51.47 |
Measurement of exposure is another important consideration when interpreting studies of pollution's effects on health. Largely, the studies employed place of residence prior to or at diagnosis to determine exposure, without accounting for places where leisure time, occupation, or daily commute might impact risk, resulting in exposure misclassification . The measurement period, duration, and latency period between subclinical and clinical rheumatic diseases might result in wrongfully attributing exposure to the diagnosis period only. The varied composition of air pollution can make it challenging to overcome the confounding effects of concurrent pollutant exposure. Here distance to roadway studies have been conducted [18, 30], but further information on which pollutants create this heightened risk is required. Yet another consideration proposed is that the range and variability in pollution levels must be sufficiently large to detect associations, which may allow detection of risks limited to higher exposure levels . | review | 99.7 |
Our systematic review included a broad search strategy in order to ensure complete identification of relevant articles. We did not perform a meta-analysis because of the small number of eligible studies identified and their heterogeneity. Our systematic review serves as a valuable resource that highlights methodological considerations that should be considered in future research studies that explore the relationship between air pollution and immune-mediated diseases. | review | 99.9 |
The existing studies suggest evidence for possible associations of PM2.5 exposure with SARDs development and JIA in younger age cohorts, but the evidence is less clear for links between air pollutant exposures and the development of RA. Additional epidemiologic work is suggested to improve upon existing analysis methods and expand studies of the effects of air pollution on disease phenotype and prognosis. More basic science and translational studies may also help to discover and explain the mechanisms behind progression from pollution related immune stimulation to the formation of antibodies and ultimately to progression of clinically apparent disease. | review | 99.8 |
Maize is one of the most important crops grown in Africa and the primary cereal grain (Smale et al., 2013). Post-harvest losses are a significant concern, reaching as high as 36% (Tefera, 2012). Insects are the major cause of dry matter loss; however, improper grain drying often results in damage by storage fungi and the risk of mycotoxin accumulation (Hell et al., 2000). The majority of smallholder farmers use traditional methods to handle and store their grain after harvest. Solar drying is effective, but it is often difficult to attain the targeted grain moisture when weather conditions are not favorable (Prakash and Kumar, 2013). Storage of the grain in woven bags is inexpensive but requires the application of insecticide (De Groote et al., 2013, Kamanula et al., 2010, Maina et al., 2016). Farmers have become more aware of the potential health issues associated with these insecticides, especially when the grain is stored within the home. | review | 98.2 |
Over the past decade, the application of hermetic storage bags has been promoted in the Sub-Sahara region for the storage of maize and other vulnerable crops (Baoua et al., 2014, De Groote et al., 2013). The bags are made of plastic with low permeability to atmospheric gases. Respiration by the grain, insects, and fungi lead to a reduction in oxygen and an increase in carbon dioxide within the hermetic bag (Murdock et al., 2012). Within a short period of time, conditions become inhibitory to insect and fungal growth and development. Although these bags cost significantly more than the traditional woven bags, the need for insecticide applications is eliminated. | study | 97.94 |
One of the concerns associated with storing maize in hermetic bags has been the efficacy for controlling the growth of mycotoxigenic Aspergillus species and the potential for aflatoxin accumulation during storage. Aflatoxins are potent carcinogens produced primarily by A. flavus and A. parasiticus (Woloshuk and Shim, 2013). Acute aflatoxicosis poses a serious risk of death, while chronic exposure is tied to cancer and a compromised immune system (Williams et al., 2004). High levels of aflatoxin contamination in Kenya maize in 2004 led to 125 deaths (Lewis et al., 2005). Because of these health risks, acceptable levels of aflatoxins in food and feed are regulated by most governments; however, significant levels are still found in many rural markets (Lewis et al., 2005). | review | 74.0 |
The use of hermetic storage for the protection of grain from aflatoxin accumulation has been tested multiple times, often with conflicting results. Williams et al. (2014) demonstrated the use of PICS bags for the storage of maize at 27 °C in laboratory conditions, showing that PICS bags mitigate the growth of A. flavus and the accumulation of aflatoxin during storage as well as maintaining the initial moisture content of the maize. Similar results were reported for the storage of shelled peanuts in hermetic bags at 30 °C (Navarro et al., 2012). However, Fusseini et al. (2016) found an increase in maize moisture content as well as aflatoxin levels during storage in triple-layer hermetic bags across multiple temperatures under laboratory conditions. Their results also indicated that cooler temperature (16 °C) resulted in the largest increase in aflatoxin accumulation. This conflicting evidence furthers the debate on the efficacy of hermetic storage for the mitigation of accumulation of aflatoxin. Under field conditions in Brazil and Kenya, the number of Aspergillus spp. increased during storage, even in hermetic storage systems (Di Domenico et al., 2016, Maina et al., 2016, Viebrantz et al., 2016). However, aflatoxin accumulation during these storage experiments did not provide conclusive evidence about the efficacy of the hermetic systems. | review | 85.1 |
In the study presented here, we determined the ability of A. flavus to grow, spread, and accumulate aflatoxin in storage bags by placing non-contaminated grain in small satchels adjacent to A. flavus-contaminated grain contaminated with aflatoxin. We compared the Purdue Improved Crop Storage (PICS) hermetics bags with polypropylene woven bags. PICS bags are a triple layer hermetic storage bag that are effective at protecting stored grains from damaging insect infestation (Baoua et al., 2014, Murdock et al., 2012). Our results demonstrate the efficacy of PICS bags for protecting the grain from moisture and temperature fluctuations during storage. | study | 100.0 |
Aspergillus flavus strain NRRL-3557 was used for this study. The fungus was grown on potato dextrose agar (PDA) medium in culture plates (100 mm × 15 mm) at 30° C for five days. To produce A. flavus-colonized maize, kernels were soaked in water overnight, then placed in mushroom-spawning bags (www.gourmetmushroomsupply.com) and autoclaved twice (Tubbs et al., 2016). A culture of A. flavus grown for five days was finely chopped and added to 500 g of autoclaved maize. The inoculated maize was incubated for 2 days at 23 °C, after which the maize was washed with water to remove conidia and dried to a moisture content of 13%. Inoculated maize (100 g) was placed in small satchels made of mesh (5.5 cm diameter). For controls, non-inoculated maize was placed into satchels. | study | 100.0 |
Maize was grown within two miles of Buck Creek Elevator (Buck Creek, IN USA), where it was purchased for this experiment. The producer harvested the grain in the fall of 2014 and dried it before placing it in on-farm storage through the winter. The grain was graded as U.S. No. 5 Yellow Corn by Titus Grain Inspection, Inc. (West Lafayette, IN, USA), a USDA licensed grain inspector. Broken corn plus foreign material (BCFM) was determined to be 5.3%. At the time of purchase, the grain moisture content (MC) was 14.0% ± 0.06% dry weight based as determined by standard protocols (Standard, 2012). | other | 99.3 |
The two types of storage bags used in this study were the triple-layer 50 kg PICS bags and single-layer 50 kg woven polypropylene bags. Bags were partially filled with 40 kg of maize, and three satchels of A. flavus-inoculated grain and three satchels of non-inoculated grain were placed in the middle of each bag. The satchels were separated by about 2.5 cm. Each bag also contained a humidity and temperature data logger (Lascar EL-USB-2, MicroDAQ, Contoocook, NH USA), which acquired data at 15-min intervals. Filled bags were placed in 31-gallon (117 L) galvanized, steel cans (68.6 cm H × 52 cm D) (Behrens Manufacturing, Winona, MN USA), which were modified by cutting four ventilation panels (41.9 cm H × 11.4 cm W) equidistant around the sides of the can. The panels were covered with screen (0.64 cm, 23-gauge steel) for rodent protection. Three replicates of the storage containers were placed at two locations and observed from June through September of 2015: the Agronomy Center for Research and Education (Purdue University, West Lafayette, IN, USA) and the Lon Mann Cotton Research Station (Marianna, AR, USA). At each location, two additional data loggers were placed outside of the bags but within the storage cans to record external humidity and temperature. | study | 100.0 |
Maize samples were collected at the start of the experiment (zero time) and after 3 months of storage. After the storage period, grain in each bag was retrieved by hand and sieved through a 3/16 inch (4.76 mm) round-hole sieve. The material passing through the sieve was stored at −20° C until insects were analyzed. At the same time, grain samples (750 g) were collected from the top, middle and bottom regions of each bag. Moisture content of the maize was determined in triplicate for the top, middle, and bottom of each bag by dry weight methods according to ASABE standards (Standard, 2012). | study | 100.0 |
To quantify surface fungi, five samples (30 g) were collected from each bag layer. Each sample was placed in a flask with 50 mL of 0.05% Triton X-100 solution and shaken for 1 min. The kernel wash was serially diluted and plated onto malt salt agar (MSA) medium (McDonough et al., 2011), and incubated for 3 days at 30 °C to obtain fungal colony counts (CFU). The resulting washed kernels were transferred to a beaker containing bleach (5% NaOCl), stirred for 1 min, and washed twice with sterile water. For each layer in the bag, three samples of 50 kernels were plated onto MSA medium. Kernel infection rate was determined by counting the number of kernels exhibiting fungal growth after three days of incubation at 30 °C. The maize in the three non-inoculated grain satchels in each bag were combined and mixed well. A subsample of 50 g was taken for aflatoxin analysis, and the remaining grain was surface sterilized and plated onto MSA medium to obtain a kernel infection rate. | study | 100.0 |
For aflatoxin analysis, a 50 g sample of maize was ground in a coffee grinder, and three subsamples (0.5 g) were extracted overnight in 2 mL of acetonitrile. The extracts were filtered (4 mm × 0.45 μm Iso-Disc Filter, Supelco, Bellefonte, PA) before injection into a Shimadzu HPLC (Shimatzu Scientific Instruments, Inc. Kyoto, Japan) equipped with an analytical C18 column (5 μm, 4.6 mm × 150 mm, Alltech Econosphere), a post-column PHRED (Aura Industries, New York, NY), and a Shimadzu fluorometer (360 nm excitation and 440 nm emission). The mobile phase consisted of water, acetonitrile, and methanol (68:24:8, v:v:v). Aflatoxin B1 was quantified by comparing peak areas with a standard (Sigma Chemical Co., St. Louis, MO) over a range of 1–100 ng aflatoxin B1/ml. | study | 100.0 |
Environmental conditions at each storage location were recorded by two data loggers placed outside the storage bags. The day/night temperatures in Arkansas were considerably warmer than in Indiana (Table 1). A high daytime temperature of 34 °C was measured in Arkansas in all three months of the study and a total of 66 days experienced temperatures above 30 °C. In contrast, the highest temperature recorded at the Indiana site was 30 °C, which was experienced on one day in July. The nighttime temperatures were cooler in Indiana than Arkansas, where 51 nighttime temperatures were below 20 °C. In July, Arkansas nights were very warm, with none below 20 °C and five nights with lows above 27 °C.Table 1Summary of temperatures recorded at experimental sites in Arkansas and Indiana in the summer of 2015.Table 1MonthHighest/LowestDays with High ≥ 30 CNights with Low ≥ 27 CNights with Low < 20CARINARINARINARINJuly34/2230/1526150017August34/2128/1420000520September34/1429/1115000814 | study | 100.0 |
The effect of the outside day/night temperatures on the grain mass was monitored with data loggers within each storage bag. Warming and cooling of the grain mass followed an oscillation similar to the outside day/night temperatures with a slight delay for heat transference (Fig. 1A and B). Over the three-month study, little difference was observed between the PICS and woven bags stored in Indiana (Fig. 2A and B). In contrast, grain in the woven bags in Arkansas was warmer in late August than in the PICS bags, likely due to the increase in insect populations (Fig. 2B). Despite this increase, the day/night oscillation was discernible.Fig. 1Oscillation of the daily temperature outside (environment) and inside the storage bags at A) Indiana and B) Arkansas. Data represent the average values from two data loggers outside and three inside the replicate bag treatments.Fig. 1Fig. 2Temperature inside the bags stored in A.) Indiana and B.) Arkansas. Data represent the average values from data loggers inside the replicate bag treatments.Fig. 2 | study | 100.0 |
During the storage period, the average relative humidity (RH) was higher in Indiana than in Arkansas (Table 2). Arkansas had 27 days, including 20 days in September, when the average RH was less than 65%. In contrast, Indiana experienced only 2 days when the average RH was less than 65%. Indiana also experienced 13 days with the average RH over 85% compared to Arkansas with only 1 day. Fluctuations in the daily RH of the outside environment had little immediate effect on the data loggers within the storage bags. However, the RH steadily increased within the woven bags stored in Indiana (Fig. 3A). In Arkansas, the RH in the woven bags increased during July, leveled off in August, and decreased during September (Fig. 3B). In contrast, the RH in the PICS bags at both locations remained unaffected by the environmental RH, remaining below 65% (Fig. 3A and B). The increase in humidity within the woven bags correlated with rewetting of the stored grain. After three months, grain stored in the woven bags increased from the initial 14.03% (SE = ± 0.4) to 15.91% (SE = ± 0.3) in Indiana and to 14.94% (SE = ± 0.9) in Arkansas. In the PICS bags, the moisture content of the grain after storage was 14.24% (SE = ± 0.2) in Indiana and 14.30% (SE = ± 0.2) in Arkansas. Grain moisture content values from PICS bags between the storage locations were not significantly different. For the woven bags, the grain moisture was significantly higher (P < 0.01) in Arkansas than in Indiana. Also, the grain moisture in PICS bags was uniform between the top, middle, and bottom layers at both locations. The moisture content was also uniform in the woven bags in Indiana, but moisture was significantly higher (P < 0.01) at 15.4% in the bottom layer of the woven bags in Arkansas. Further analysis showed no significant difference (P < 0.01) between the replicates of each treatment.Fig. 3Relative humidity inside the bags stored in A.) Indiana and B.) Arkansas. Data represent the average values from data loggers inside the replicate bag treatments.Fig. 3Table 2Summary of relative humidity recorded at experimental sites in Arkansas and Indiana for the summer of 2015.aTable 2Number of daysHighest/Lowest>85%84%–75%74%–65%<65%ARINARINARINARINARINJuly91%/48%100%/52%010141616510August93%/43%95%/51%13911151760September87%/27%92%/47%0039713202aAverage daily relative humidity was calculated from 96 data points collected over 24 h period. | study | 100.0 |
The initial grading of the maize used in this study did not reveal any evidence of insect infestation. However, after three months of storage, insects were present under all treatments (Table 3). When the woven bags in Arkansas were opened, a large number of adult Indian meal moths (Plodia interpunctella) were present at the grain surface. Only a few moths were observed in the woven bags stored in Indiana. No Indian meal moths were observed when the PICS bags were opened. All grain in the storage bags was passed through a sieve to collect the insects. In the three woven bags from the Arkansas location, 841 (SE = ± 62) insects per kg of maize were counted, which was significantly (P < 0.01) more than the 10 (SE = ± 1.2) insects per kg of maize in the PICS bags. Maize weevil (Sitophilus zeamais) was the predominate insect. Also present were parasitic wasps, rusty grain beetles (Cryptolestes ferrugineus), and unidentified beetles and insect larvae. Insect populations were lower in Indiana, with 25 (SE = ± 1.1) and 5 (SE = ± 0.8) insects per kg of maize in the woven and PICS bags, respectively. There was a significant difference (P < 0.01) between the bag types, and the insects identified were similar to those found in Arkansas.Table 3Number of insects in PICS and woven bags after three months of storage in Indiana and Arkansas.aTable 3IndianaArkansasPICSWovenPICSWovenTotal5.0 ± 0.8 Ac25 ± 1.1 A10 ± 1.2 A841 ± 61.7 BWeevils3.9 ± 0.8 A19 ± 2.1 A2.1 ± 0.5 A589 ± 37.4 BBeetles0.1 ± 0.06 A3.5 ± 1.0 A7.0 ± 1.3 A66 ± 5.4 BParasitic Wasps0 A0 A0 A132 ± 14.6 BIMMb0 A0.1 ± 0.05 A0 A4.2 ± 0.6 BLarvae1.0 ± 0.3 A1.4 ± 0.6 A0.7 ± 0.2 A46 ± 10.4 BaValues are the mean number of insects per kg of maize ± SE.bAdult Indian Meal Moths.cLetters represent significance (P < 0.01) across each row. | study | 100.0 |
Grain collected from the top, middle, and bottom layers of each storage bag was analyzed to determine the number fungi on the kernel surface and the number of infected kernels. The number of fungi washed from the surface of the initial grain used for storage was 1.3 × 103 (SE = ± 302) CFU/g of maize. Fusarium and Penicillium were the major genera identified on the culture medium. After three months of storage, the most predominant fungi were Fusarium, Penicillium, and Aspergillus species. Alternaria species were also observed as well as other sporulating fungal colonies and yeast-like fungal colonies. In Indiana, 9.8 × 103 (SE = ± 637) CFU/g of maize was washed from the grain stored in the woven bags, compared to 3.7 × 103 (SE = ± 878) CFU/g of maize in the PICS bags. The number of fungi on the maize in the Arkansas PICS bags was not significantly different (P < 0.01) than the Indiana PICS bags (2.8 × 103 (SE = ± 481) CFU/g of maize). In contrast, grain in the woven bags in Arkansas had 3.0 × 105 (SE = 1.0 × 105) CFU/g of maize. Our analysis indicated no significant difference in the number of surface fungi between layers except in the woven bags stored in Arkansas (P < 0.01). In two of the replicate bags, the bottom layer had significantly (10-fold) more surface fungi than other layers, and in the third replicate bag, the middle had significantly more fungi than other layers. Overall there was no significant difference (P < 0.01) between replicates of each bag type for a given environment. | study | 100.0 |
Fungal infection of the initial grain kernels was approximately 22%. After three months of storage in PICS bags, the infection level remained essentially unchanged in both locations (Fig. 4). In the woven bags stored in Indiana the number of infected kernels increased significantly (P < 0.01) to 32% and to 49% in the Arkansas grain (Fig. 4). The predominant genera identified were Fusarium, followed by colonies of Aspergillus and Penicillium.Fig. 4Effect of bag type on kernel infection and seed germination after three months of storage. Data are the mean value of three replicate bags, and bars represent SE. Symbols (*) represent significant differences (P < 0.01) from the initial infection (22% ± 2.8%) and germination (43% ± 1.0%).Fig. 4 | study | 100.0 |
Effect of bag type on kernel infection and seed germination after three months of storage. Data are the mean value of three replicate bags, and bars represent SE. Symbols (*) represent significant differences (P < 0.01) from the initial infection (22% ± 2.8%) and germination (43% ± 1.0%). | study | 100.0 |
The initial germination rate of the maize before storage was 43%. Regardless of bag type or location, germination decreased significantly (P < 0.01) from the initial germination rate after three months of storage (Fig. 4). At the Indiana location, the germination was reduced by 3% in the PICS bags and 12% in the woven bags (Fig. 4), and in Arkansas there was a 12% reduction in the PICS bags and 26% in the woven bags. There was no significant difference (P < 0.01) between the layers within each bag, except in one replicate of the woven bags stored in Arkansas. In this bag, the germination was significantly lower in the bottom layer of the bag. There was no significant difference (P < 0.01) between replicates of each bag type for a given environment. | study | 100.0 |
The initial aflatoxin B1 (AFB1) concentration in the A. flavus-colonized maize placed in satchels was 13.9 μg of AFB1 per kg of maize (SE = ± 0.65 μg/kg). After three months of storage in Indiana, the AFB1 concentration decreased to 2.07 μg of AFB1 per kg of maize (SE = ± 0.09 μg/kg) and 2.72 μg of AFB1 per kg of maize (SE = ± 0.33 μg/kg) in the PICS and woven bags, respectively. A similar reduction was measured in the Arkansas grain, with 2.28 μg of AFB1 per kg of maize (SE = ± 0.16 μg/kg) in the PICS bags and 2.05 μg of AFB1 per kg of maize (SE = ± 0.12 μg/kg) in the woven bags. For both bag types and both locations, no aflatoxin was detected in the non-inoculated grain placed in satchels adjacent to the A. flavus-colonized maize satchels. | study | 100.0 |
Maize grown in the Sub Sahara is often contaminated with aflatoxins due to an ear rot disease caused by A. flavus and poor postharvest handling (Atehnkeng et al., 2008, Mukanga et al., 2010, Setamou et al., 1997, Wagacha and Muthomi, 2008). Non-uniformity of the contamination within a grain mass leads to high variability in aflatoxin assessments and results that often conflict with expected norms (Mallmann et al., 2014). The maize used in this study was ideal for addressing the efficacy of hermetic storage. The amount of grain dust and BCFM, which contributed to a U.S. No. 5 grading, increased the vulnerability of the grain to insect and fungal invasion as well as moisture absorption. Additionally, the two storage locations (Indiana and Arkansas) provided environmental conditions that were starkly different. The placement of satchels of aflatoxin-free grain in close proximity to highly contaminated grain allowed us to address the central question of whether aflatoxin accumulation occurs in either the PICS or woven bags during storage. | study | 100.0 |
Placement of temperature/humidity data loggers inside the storage bags provided new information about the changes occurring in response to daily environmental conditions. The diffusivity of heat through bulk maize is influenced by the moisture content and porosity (Kustermann et al., 1981). The diurnal change in the environmental temperature resulted in cyclic heating and cooling of the grain; however, the center of the grain mass, where the data logger was located, never reached equilibrium with the outside temperature. These temperature characteristics where not impacted by the type of storage bag or location. The hermetic seal of the PICS bags shielded the grain from changes in the external relative humidity, resulting in little impact on the RH within the grain mass or in grain moisture content. Within the woven bags, the data loggers did not detect daily changes in external RH; however, the RH gradually increased with time as did the grain moisture content. At the Arkansas location, during a period in September when the external RH was low resulted in a decline in the internal RH. Stored grain can exchange moisture with the environment and reach an equilibrium point (Pixton and Warburton, 1971). Williams et al. (2014) observed that low (29%) RH resulted in the drying of grain stored in woven bags but not PICS bags. We speculate that the September period of lower RH in Arkansas contributed to the lower final moisture content of the grain compared to grain in the Indiana experiment. | study | 100.0 |
Regardless of the higher humidity at the Indiana site and the higher temperatures in Arkansas, aflatoxin was not detected in the grain after three-months of storage in either the PICS or woven bags. Sauer and Burroughs (1980) found that spread of A. flavus and aflatoxin accumulation was minimal at 16.5% maize moisture content, but growth and mycotoxin accumulation was extensive at 17.4%. A greater amount of rewetting occurred in the grain stored in the Indiana woven bags (2.9%), which resulted in a final moisture content (15.9%) that was below these minima for A. flavus and aflatoxin. We also observed a decrease of 75–80% in AFB1 in the satchels containing the A. flavus-contaminated maize. The reason for the decrease is unclear. The only example we found in the literature where aflatoxin contamination decreased was in field experiments conducted in North Carolina (Payne et al., 1988). The authors observed that aflatoxin contamination levels increased in A. flavus-infected kernels until maturity and then decreased during the dry-down period. | study | 100.0 |
Although conditions within the woven bags were not conducive for spread of A. flavus to non-infected grain, there was a 50% and 130% increase in kernels infected by other fungi in Indiana and Arkansas, respectively. These fungi included Aspergillus, Fusarium and Penicillium species, which have been identified previously in stored maize by others (Adisa, 1994). Many of these fungi are xerophiles capable of growth at moisture levels between 13 and 14.5% (Christensen, 1957). | study | 99.94 |
The optimal temperature for the growth and development of storage insects is between 25 and 33 °C, and growth is slower when temperatures are outside this range (Fields, 1992). Over the three-month storage period, weather at the two experimental sites (Indiana and Arkansas) experienced starkly different temperatures, which resulted in differences in the final insect counts. In Indiana, a temperature above 27 °C was recorded on only one day and nighttime lows below 20 °C were recorded on 51 days. In contrast, Arkansas experienced only 13 nights with temperatures below 20 °C and 66 days with daytime highs above 27 °C. The highest temperature recorded in Arkansas was 34 °C, which was reached on seven days. As a result of these conditions, insects in the Arkansas bags were 34-times (woven bags) and 2-times (PICS bags) higher than in Indiana. The vast majority of the insects were weevil species. Throne (1994) found that maize weevil (Sitophilus zeamais) development takes about five weeks, suggesting that under optimum conditions about two to three generations of weevils could develop during the 12-week storage experiment. Throne (1994) also described the propensity of females to lay more eggs under optimal temperature and humidity, which was near ideal in Arkansas and reflected in the large number of insects in the woven bags. Insects found in the PICS bags after the storage period indicate that the initial grain contained weevil and beetle eggs. In Arkansas, where environmental conditions were optimal for development of these eggs into larvae and adult insects, the PICS bags reduced insect development by greater than 80-fold compared to development in the woven bags. Even in Indiana, the PICS bags controlled insect numbers more effectively than the woven bags. These results are in agreement with many studies that have documented the efficacy of PICS and other hermetic bags (Amadou et al., 2016, Baoua et al., 2014, Murdock et al., 2012, Mutungi et al., 2014, Njoroge et al., 2014). | study | 99.94 |
It is a well-documented phenomenon that the respiration of established fungal pockets combined with the respiration of insects can create hot spots within stored grain (Sinha and Wallace, 1966, Wallace and Sinha, 1962). This process of heating was observed in the woven bags stored in Arkansas. Wallace and Sinha (1962) showed that the development of these hot spots leads to the establishment and spread of Penicillium and Aspergillus species while the viability of persisting field fungi diminishes. Sone (2001) found A. glaucus infected 52.0% of kernels after 80 days of storage with weevils in maize at 13% moisture content, 26.6 °C, and 60% RH. Sinha (1984) suggested that the microclimate created by insects increases temperature and relative humidity making conditions conducive to the growth of storage fungi. Sinha and Sinha (1992) found that, with maize stored in ventilated glass bottles without insects, moisture content increased from an initial 13.9%–14.3%. When the maize was infested with S. oryzae and Tribolium castaneum, the moisture increased to 25%. Furthermore, these researchers reported that, in grain containing insects and inoculated with A. flavus, the moisture content rose to 26.4% after 10 weeks of storage. The spread of A. flavus to kernels also increased from 8% to 100%. In our study, the woven bags stored at the Arkansas location contained significantly more insects in the bottom compared to the top and middle. Considering that the fungal counts in the bottom layer were 10-fold higher than the top and middle, the combination of fungal and insect activity did not result in grain moisture content in the bottom layer greater than 15.9%, which is below the optimum for A. flavus. | study | 100.0 |
In summary, our results show that the use of hermetic storage mitigates many of the environmental effects that lead to the spoilage of grain. Hermetic storage provides a barrier to the exchange with environmental moisture, preventing rewetting that can contribute to the proliferation of storage fungi. Our results also support previous research showing that hermetic storage bags protect maize from insect infestation and development. Although conditions in the woven bags never became conducive for the spread of A. flavus, other storage fungi were able to proliferate throughout the woven bags due to optimal conditions of moisture. The placement of A. flavus-colonized and non-colonized maize in small satchel provided evidence that A. flavus spread and aflatoxin accumulation does not occur if the grain moisture content is not optimal. These results also suggest that protocols for sampling storage must account for high aflatoxin-containing kernels within the bags that can lead to variability and potential erroneous conclusions about the efficacy of hermetic bags. Ultimately, this study demonstrated the use of PICS bags as a practical option for storing and protecting grain from a variety of detrimental environmental effects. | study | 99.94 |
Approximately 5 billion people lack adequate access to surgical care . This issue disproportionately affects those in low- and middle-income countries (LMICs), such that the poorest 30% of the world receives only about 3.5% of surgical procedures . This has led to the loss of 77.2 million disability-adjusted life years (DALYs) and 16.9 million lives each year, with profound social and economic implications. Unfortunately, those who become disabled due to lack of surgical care can no longer participate effectively in the workforce. Subsequently, individual families fall deeper into poverty, and as this issue affects entire populations, LMICs face difficulties in advancing economically. If the lack of access to surgical care worldwide is not addressed, the global economy is estimated to lose 20.7 trillion dollars between 2015 and 2030, with 12.3 trillion dollars being lost from LMICs alone . This would have a significant negative impact on the development of LMICs and would perpetuate global economic inequities that have persisted for many years. | other | 72.2 |
The global burden of surgical disease is being addressed in several ways, outlined specifically in Chapter 13 “Specialized Surgical Platforms” of “Essential Surgery: Disease Control Priorities” . One way is through humanitarian work on the part of surgeons from high-income countries (HICs) going to LMICs for shorter missions and performing surgery on patients [4–6]. For example, Dell Children’s Global Surgical Outreach goes to Guatemala several times a year and does a large volume of pediatric surgery cases . This work can also involve major organizations like Operation Smile, dedicated to providing year-round care for specific surgical needs via scheduled rotations of surgical teams . | other | 99.9 |
Although there are direct benefits to providing surgical care in LMICs, there may also be unintended consequences in the long-term [4, 6, 9]. Not all patients are able to receive operations during surgical missions, and those that do may not receive follow-up care, because the necessary resources are not always in place to provide it . Local surgeons may feel demotivated when local patients are treated as a part of surgical care missions that they are not involved in . Some groups in HICs also provide surgical equipment/resources for LMICs; however, it is generally difficult to keep that equipment running, often due to the lack of technicians and parts. These interventions do have an important place within global surgery efforts and provide some immediate relief for the burden of surgical disease, but they may not have long-term benefits . Currently, the field of global surgery has put an increasing focus on building capacity and surgical infrastructure with long-term goals for improving access to surgical care worldwide. | review | 99.75 |
An education-based solution may be more sustainable for addressing the global burden of surgical conditions . Currently, 2.2 million more surgeons, anesthesiologists, and OB/GYNs are needed to address the global need for surgery . Without the proper surgical workforce, it may be difficult to scale up surgical care to meet the World Health Organization's and Lancet Commision on Global Surgery's goals for 2030 [3, 13]. In addition to providing clinical care in LMICs, efforts are becoming increasingly focused on teaching surgery and helping set up surgical residency programs through effective partnerships [14, 15]. There are many ways in which this is being done. Some have created online education platforms for surgical residents in LMICs, while others have brought surgical residents from LMICs to HICs for specialized training. International surgical teaching collaborations (ISTCs) focus on building surgical education infrastructure in LMICs to address the needs for clinical care, training, and research – the “tripartite needs” of global health – and often times also utilize some of the above-mentioned modalities to achieve those goals . | review | 99.5 |
ISTCs can increase surgical capacity in LMICs to alleviate some of the social and economic repercussions of lack of access to surgical care . ISTCs involve working with local surgical providers in LMICs and adapting the education to local needs, which can help reduce brain drain . The goal is for sustainable and systematic collaborative relationships to be formed to help increase the surgical capacity of LMICs [16, 17]. | other | 99.9 |
Currently, ISTCs do not have a standard operational process. On a small scale, a surgical team from a HIC may partner with a team from a LMIC to teach surgical procedures that they want to learn through a short training course – for example, Dr. Mark Bernstein teaches the awake craniotomy in many low-resource settings around the world . This helps address very specific needs in a local setting, often the most pressing issues, and can be significantly valuable to patients in that locality. On a larger scale, there are a variety of models for ISTCs. The Foundation of International Education in Neurological Surgery (FIENS) is an organization dedicated to developing neurosurgical education worldwide [19, 20]. The Toronto Addis Ababa Academic Collaboration (TAAAC) is a full institutional collaboration that has led to the development of education programs in many different medical and surgical specialties at Addis Ababa University in Ethiopia through partnership with the University of Toronto . This larger scale model focuses on building the surgical capacity of major academic institutions in LMICs. However, by also focusing on training future trainers, ISTCs can build the capacity of those institutions to reach out to underserved rural areas of their countries . These larger collaborations often involve not only local stakeholders, such as surgeons, anesthesiologists, nurses, and hospital staff, but national stakeholders as well, including the Minister of Health, Minister of Finance, and others who can provide a more comprehensive perspective on the progress of these efforts. | other | 99.3 |
Health partnerships have been a part of global health for many years, but have only recently become a significant part of global surgery efforts. Since ISTCs are becoming more prevalent, there are challenges that need to be resolved. Global surgery efforts have been fragmented, because the tendency towards horizontal interventions focused on building health systems and infrastructure, as opposed to vertical interventions focused on specific diseases, has increased more in recent years . Thus, global surgery efforts are often individually initiated, planned, and carried out. There is minimal organization, systematization, or communication between groups. This is increasingly becoming an issue as efforts expand and overlap. Organizations such as the Lancet Commission on Global Surgery (LCoGS), Global Partners in Anesthesia and Surgery (GPAS), Program for Global Surgery and Social Change (PGSSC), and others are working towards making surgery a global health priority and towards increasing recognition of the value of educational collaborations in achieving more equity in the distribution of surgical care worldwide . The LCoGS has added considerable amounts of research to the field and published a landmark paper in 2015 that led to a surge of interest and involvement in global surgery . PGSSC similarly has more recently added research to the field but has also worked with LMICs to create and implement national surgical, obstetric, and anesthesia strategic plans that were suggested by the Lancet Commission’s work. GPAS is one of the earlier global surgery organizations that is geared towards capacity-building, research, and harmonization of global surgery efforts. Additionally, professional bodies such as the College of Surgeons of East, Central, and Southern Africa (COSECSA), the West African College of Surgeons (WACS), the Royal College of Surgeons (RCS), and the American College of Surgeons (ACS), are increasingly pushing the agenda of global surgery in the academic arena. | review | 99.9 |
Priority needs to be given to fostering a unified approach to ISTCs by working off of the currently fragmented system . In this paper, we seek to examine the elements of a framework for unifying, systematizing, and improving the quality of international surgical teaching collaborations from the perspective of those in HICs. Our hope is for a similar study to be carried out in LMICs such that the combined results can inform the next steps in sustainable global surgery efforts. | other | 99.5 |
Study participants included surgeons from multiple specialties (general, orthopedics, OB/Gyn, neurosurgery, cardiothoracic, oncology, plastics), anesthesiologists, other physicians (family medicine, emergency medicine, palliative care, radiology, psychiatry), residents, nurses, academics, and administrators from 20 academic medical institutions in the U.S., Canada, and Norway. | study | 99.7 |
Study participants were known by the senior author and were recruited via convenience sampling. 124 people were emailed to participate in the study, and the final sample size was 68. 92 participants responded to the email, 23 did not respond, and 9 were unable to find time to schedule the interview. 68 of those interviewed had involvement in international medical or surgical teaching collaborations in some capacity, and the other 24 participants’ data was not included in this analysis. Of the participants, 62 were healthcare providers involved in international medical or surgical teaching collaborations (40 surgeons, 5 anesthesiologists, 11 additional physicians, 4 surgery residents, 2 nurses). The remaining 6 participants included academics and administrators. “Involvement” in international medical and surgical teaching collaborations included participants who had a current continued and sustained commitment. | study | 100.0 |
From June 1–August 1, 2015 in Toronto, Canada, P.F. conducted 68 semi-structured interviews in-person, over the phone, or over Skype. In-person interviews took place in the participants’ academic offices within their hospitals, and phone/Skype interviews were conducted in an office space within Toronto Western Hospital. Toronto was chosen due to the location of the senior author; however, participants were not limited to Toronto as phone calls and Skype conversations allowed for a broader reach. 68 interviews were sufficient to reach data saturation, as themes began to repeat amongst the different interviews. | study | 56.78 |
Questions were based on an interview guide developed by P.F. and M.B. and were intended to be open-ended to gain more in-depth responses. Demographic data collected included age, gender, specialty, and number of years in practice. Interviews were approximately 40 min long on average and were audio-recorded. No repeat interviews were carried out. Interviews were transcribed by P.F. from August 2015 to November 2015. Transcripts were not returned to participants for comment or correction. The complete list of interview questions is attached as Additional file 1. | study | 99.9 |
Transcripts of the audio files were analyzed by P.F. using content analysis [25, 26]. This included finding, examining, and recording patterns in the data. Themes were determined inductively after coding the data. Data integrity was verified by M.B., who has substantial experience in qualitative research methodology. Software was not used for the data organization and coding. Study participants were not asked to provide feedback on the findings. | study | 99.94 |
Each participant gave either written or oral informed consent to participate in the study. All recordings and transcripts were de-identified and stored confidentially, and the recordings and transcripts were kept in a secure location. The study was approved by both the Research Ethics Board at the University Health Network in Toronto, Ontario, Canada (reference number 15–9030-AE) and by the Institutional Review Board at the University of Texas at Austin, Austin, Texas, USA (reference number 2015–05-0040). | other | 99.7 |
A convenience sample was used for the study, so there was slightly larger representation from one locality. Additionally, due to qualitative methodology, the results may not be generalizable. The large sample size was intended to help address these limitations. In general, the findings from qualitative research rely on the skills of the researcher, which may lead to some bias in the results. There is also more difficulty in assessing the rigor of the study since quantitative measurements were not used. It is also implausible to visually characterize the qualitative findings. However, qualitative research provides a more in-depth analysis of the practical issues within global surgery that quantitative measurements cannot characterize. | study | 99.94 |
Another limitation is that LMICs were not included in the study. The purpose of the study was to characterize the issues causing fragmentation in global surgery efforts from the perspective of those in HICs, which is why only participants from HICs were interviewed. The perspective of those in LMICs is vital to this discussion; however, separately characterizing issues experienced by LMICs can allow those issues to be addressed specifically. A similar study should be done in LMICs to assess needs for unifying, systematizing, and improving global surgery efforts, and the authors are presently aiding colleagues in LMICs with this effort. | other | 75.44 |
Six themes emerged in regards to unifying, systematizing, and improving the quality of ISTCs: consolidation, communication and collaboration, a system of support, a scholarly approach, increased use of technology, and concerns/hesitations. Some themes included subthemes, as presented below. | other | 99.9 |
Participants reported that there are no central global surgery offices at their institutions, so the efforts are too fragmented and each hospital has its own projects. Participants felt that structure was necessary to create priorities and that it was the institution’s responsibility to implement structure. They expressed that there should be a few flagship projects from each institution with more coordination and focus. “I think if we appointed a head of global health and gave that person some resources and a mandate, then you have a structured global health initiative.” –OB/Gyn, Canada | other | 99.94 |
Participants mentioned a need for a centralized website that lists those involved in ISTCs and capacity-building efforts by specialty and country. The website would also need to include past, present, and future ISTCs so that surgical healthcare providers could easily connect rather than having to look through multiple sources. “In this day and age, we need a website that really takes into account every volunteer opportunity in the world and every volunteer in the world that is planning to go.” –Neurosurgeon, USA | other | 99.94 |
Participants felt this could facilitate teamwork and learning, and that it could avoid duplication. A website could also help match the need for specific surgical specialties in LMICs with the available surgical healthcare providers in HICs who wish to help address that particular need. | other | 99.94 |
Participants reported that meetings to reflect on the progress of ISTCs would be beneficial. Specifically, participants felt that they should more regularly discuss the goals and social values of ISTCs, as well as the effectiveness of current approaches and strategies for improvement. “Finding out what made [particular ISTCs] work and rolling out more of those [positive elements] would be much more efficient than everybody trying to figure it out by themselves.” –Neurosurgeon, USA | other | 99.9 |
Participants reported a need for all parties involved in ISTCs to communicate and collaborate more effectively. Participants emphasized the particular importance of having government support for ISTCs, as most governments have control over healthcare in LMICs. “I think the overall answer is that it requires different parties coming together. It’s a lot of collaboration, a lot of interconnectivity, a lot of liaising at community levels all the way up to governments and donors.” –Global Surgery Administrator, Canada | other | 99.94 |
“I think the overall answer is that it requires different parties coming together. It’s a lot of collaboration, a lot of interconnectivity, a lot of liaising at community levels all the way up to governments and donors.” –Global Surgery Administrator, Canada | other | 99.94 |
Participants also mentioned the importance of collaboration in reducing redundancy of efforts. They shared that often times, they do not know about colleagues’ involvement in ISTCs within their own departments, making it difficult to support others’ efforts. | other | 99.94 |
Participants mentioned a need for administrative staff to help sustain ISTCs. They reported that administrators could plan and organize trips, reach out to donors, and build departmental global surgery plans. Participants also reported that administrative staff could help form ISTCs by doing initial outreach and creating partnerships with institutions abroad. “If we can bring in some administrative people or some kind of political involvement, and also have some kind of knowledge on how to create these global partnerships, I think it’ll be so much more helpful.” –Global Surgery Administrator, Canada | other | 99.94 |
Participants reported the need for more money to support global surgery and that it is difficult to secure the necessary funds due to the long-term nature of ISTCs. “We do get into a trap of always having to come up with dollars, so that certainly is a difficult thing. I would like to see more money in the department of surgery to support global surgery, as it is becoming an extremely important topic around the world.” –Pediatric Neurosurgeon, Canada | other | 99.94 |
“We do get into a trap of always having to come up with dollars, so that certainly is a difficult thing. I would like to see more money in the department of surgery to support global surgery, as it is becoming an extremely important topic around the world.” –Pediatric Neurosurgeon, Canada | other | 99.94 |
Participants felt that global surgery needs to be professionalized. They pointed out that there should be minimum standards for ISTCs in order to avoid possible negative ramifications for LMICs. Participants also mentioned the need for global surgery to be recognized as an academic field so that it could encourage more research and formal study. “I think [ISTCs] are great as long as there’s an academic vent to what you’re doing, and I think there should be, because anything new that we do is open to and potentially should be studied in some formal way.” –Neurosurgeon, Canada | other | 99.9 |
Participants reported that many different academic fields involved in global surgery work are not engaged collaboratively. They felt that ISTCs could be significantly enhanced by interdisciplinary involvement. Participants mentioned the need to think broadly about different disciplines involved in surgical work and to apply those same components to ISTCs. “Part of it is to engage communities that are in siloes that don’t often engage in these things together. The other part of it is to start coming up with a shared language, perspective, and attitude towards international engagement.” –Medical Education Researcher, Canada | other | 99.9 |
“Part of it is to engage communities that are in siloes that don’t often engage in these things together. The other part of it is to start coming up with a shared language, perspective, and attitude towards international engagement.” –Medical Education Researcher, Canada | other | 99.94 |
Participants mentioned the need for respect when engaging in ISTCs. They emphasized the importance of recognizing that those in LMICs know more about what can be accomplished within their own environment than visitors do. Participants pointed out that surgical healthcare providers in LMICs can perform some surgical procedures more effectively than those in HICs and that the value of their expertise should be acknowledged. Participants said they could learn how to use fewer resources for surgical procedures from their colleagues in LMICs. “It’s very helpful for clinicians [from HICs] to see what can be done with fewer resources, which is one of the things they can learn, since [surgeons from LMICs] have learned to be more efficient in certain things that they do.” –Psychiatrist, Canada | other | 99.9 |
Participants reported a need for research that assessed the surgical needs of specific hospitals and areas in LMICs. They wanted to know what resources those in LMICs have and whether those resources are amenable to building surgical care infrastructure. They also wanted to know what the surgical healthcare providers in these specific sites want to learn. They also mentioned the need for education research that could address how to most effectively teach surgery in low-resource settings. | other | 99.9 |
Participants pointed out a need for outcomes research. They said that they need to know if ISTCs are actually improving surgical capacity in LMICs and that measuring effectiveness could help identify the best methods for conducting ISTCs. Longitudinal outcomes research also ensures that time and resources are being used efficiently. Participants mentioned the need for developing a system of metrics to consistently measure the impact of ISTCs and other capacity-building efforts. | other | 99.9 |
Participants expressed that using technology allows inclusion of more surgical healthcare providers in ISTCs, because it provides an alternative to traveling and teaching. Additionally, participants mentioned that online technology and educational materials help standardize surgical education by making information readily available and more equally accessible to all. Participants reported using technology that ranged from online teaching modules to cameras in operating rooms to robotic surgery. They also pointed out that certain basic skills can be taught and certain cases can be discussed using video interfacing. “One of the great things about technology is that it offers every good surgeon in the world [a chance] to contribute, if they can, let’s say, record their surgery… I think technology plays a great role in the sense that it can empower people in any part of the world to be able to level the playing field, and it can allow them to be a valuable contributor.” –Ophthalmologist, USAParticipants did point out that although technology is important, it cannot replace having a physical presence in LMICs. They felt that in-person collaboration is necessary, but that technology has the potential to maintain ISTCs over distance and time. | other | 99.44 |
“One of the great things about technology is that it offers every good surgeon in the world [a chance] to contribute, if they can, let’s say, record their surgery… I think technology plays a great role in the sense that it can empower people in any part of the world to be able to level the playing field, and it can allow them to be a valuable contributor.” –Ophthalmologist, USA | other | 99.94 |
Participants raised concerns that organizing ISTCs could lead to over-regulation and bureaucracy. They mentioned potential increased costs, paperwork, and other barriers, which could lead to a decreased quantity of ISTCs. “But I would worry that in organizing [ISTCs] more, you’re also subjecting these efforts to regulation that just makes it harder to happen, increases the cost, and increases the time to jump through administrative procedures.” –Global Surgery Administrator, USA | other | 99.94 |
“But I would worry that in organizing [ISTCs] more, you’re also subjecting these efforts to regulation that just makes it harder to happen, increases the cost, and increases the time to jump through administrative procedures.” –Global Surgery Administrator, USA | other | 99.94 |
Participants pointed out that sometimes surgical healthcare providers take an individualistic approach to ISTCs that may make it difficult to consolidate efforts. They expressed that surgical healthcare providers are driven people and want to be involved in ISTCs on their own without needing to get approval from others. An unfortunate side effect of this is that those involved in ISTCs do not disclose with each other, as they should, what they have done and what they know regarding global surgery work. “I think the thing is as surgeons and physicians in general, we are driven people, so we think whatever we decide to do is the best way to do it, and whatever other people are doing is a waste of resources.” –Neurosurgery Resident, Canada | other | 99.9 |
Participants also had questions about whether ISTCs should have a decentralized, technique-based focus in which one procedure is taught at multiple sites, or a centralized, site-based focus in which the comprehensive surgical needs of a site are addressed. For a decentralized approach, participants mentioned that it could allow for diversity and smaller, more manageable tasks. For a centralized approach, participants felt that it could streamline ISTCs and allow for all of those involved to take on a more organized integrated approach. | other | 99.9 |
Lack of organization and a systematized process for involvement in ISTCs is a major barrier to their success. This section describes suggestions/models that can be implemented to better organize ISTCs, based on participants’ interviews. Figures 1, 2, 3, 4 and 5 summarize and consolidate the points below in a framework for a unified approach to ISTCs and sustainable global surgery efforts.Fig. 1Centralized Website for Consolidating Information on ISTCs and Sustainable Global Surgery Efforts. A website for ISTCs and sustainable global surgery efforts should be universally accessible, have international coverage, and potentially be facilitated by professional bodies. The website could include names and identifying information of those involved, surgical specialty focus, where the group is from, where they are engaging in work (or what type of work is needed), a description of the global surgery work, learning points to share with others, and the current needs for sustaining the work. Other information could be included as well. This website could allow relevant stakeholders to look at current efforts, contact those involved and learn more, engage in new work based on needs, and/or initiate collaborations based on similarities of surgical specialty, regions, etc. Fig. 2Expansion and Consolidation of ISTCs with Consistent Action and Reflection. This figure integrates the framework of action and reflection with that of expansion and consolidation. Action includes the expansion phase, which leads to more ISTCs, and the consolidation phase, which strengthens partnerships and focuses on long-term outcomes. Reflection includes meetings and conferences from the local to the national levels in order to assess the successes and failures of interventions Fig. 3A Scholarly Approach to Global Surgery Efforts. A scholarly approach to global surgery work can further formalize efforts. Integral to this is increasing academic recognition of global surgery, increasing research on needs and outcomes, an interdisciplinary approach that engages multiple relevant fields (all of which are not listed), and consistent program evaluation Fig. 4The Role of Technology in Facilitating Continued Long-Distance Partnerships. Sharing cases, having joint teaching rounds, sharing textbooks/journal articles, developing curricula, and engaging in telesimulation are all ways in which technology can be used to further advance ISTCs and global surgery efforts, although there are many other possibilities. Use of technology can encourage collaboration, lead to continuous learning and partnerships, and increase global connections and networks Fig. 5Roles of a Single Multi-Level Global Surgery Administrative Structure. Local, national, and international boards working in conjunction as a single multi-level administrative structure can unify ISTCs and other sustainable global surgery efforts. Working at a grassroots level, local global surgery boards can directly monitor and engage in local global surgery efforts, assess local needs, and share these needs with the relevant national global surgery board. These national boards can then monitor local efforts and guide resources and funding to underserved areas, while consolidating requests to share with the international board. The international board tracks global surgery efforts, receives requests/needs from the national level, consolidates data/research, tracks funding, and disseminates data and knowledge of successes/failures down to national boards, who can then share this global information to those working on the local level | review | 99.9 |
Centralized Website for Consolidating Information on ISTCs and Sustainable Global Surgery Efforts. A website for ISTCs and sustainable global surgery efforts should be universally accessible, have international coverage, and potentially be facilitated by professional bodies. The website could include names and identifying information of those involved, surgical specialty focus, where the group is from, where they are engaging in work (or what type of work is needed), a description of the global surgery work, learning points to share with others, and the current needs for sustaining the work. Other information could be included as well. This website could allow relevant stakeholders to look at current efforts, contact those involved and learn more, engage in new work based on needs, and/or initiate collaborations based on similarities of surgical specialty, regions, etc. | other | 99.94 |
Expansion and Consolidation of ISTCs with Consistent Action and Reflection. This figure integrates the framework of action and reflection with that of expansion and consolidation. Action includes the expansion phase, which leads to more ISTCs, and the consolidation phase, which strengthens partnerships and focuses on long-term outcomes. Reflection includes meetings and conferences from the local to the national levels in order to assess the successes and failures of interventions | other | 99.94 |
A Scholarly Approach to Global Surgery Efforts. A scholarly approach to global surgery work can further formalize efforts. Integral to this is increasing academic recognition of global surgery, increasing research on needs and outcomes, an interdisciplinary approach that engages multiple relevant fields (all of which are not listed), and consistent program evaluation | other | 99.94 |
The Role of Technology in Facilitating Continued Long-Distance Partnerships. Sharing cases, having joint teaching rounds, sharing textbooks/journal articles, developing curricula, and engaging in telesimulation are all ways in which technology can be used to further advance ISTCs and global surgery efforts, although there are many other possibilities. Use of technology can encourage collaboration, lead to continuous learning and partnerships, and increase global connections and networks | other | 99.94 |
Roles of a Single Multi-Level Global Surgery Administrative Structure. Local, national, and international boards working in conjunction as a single multi-level administrative structure can unify ISTCs and other sustainable global surgery efforts. Working at a grassroots level, local global surgery boards can directly monitor and engage in local global surgery efforts, assess local needs, and share these needs with the relevant national global surgery board. These national boards can then monitor local efforts and guide resources and funding to underserved areas, while consolidating requests to share with the international board. The international board tracks global surgery efforts, receives requests/needs from the national level, consolidates data/research, tracks funding, and disseminates data and knowledge of successes/failures down to national boards, who can then share this global information to those working on the local level | other | 99.94 |
A centrally accessible website with comprehensive information on ISTCs could list surgical healthcare providers worldwide who are engaged in global surgery work, along with their specialty/subspecialty, where they are from, where they are going, and other pertinent information. This could allow surgical healthcare providers to easily find opportunities for involvement. This could also provide a way for those involved to contact each other and to learn from each other’s work, while also creating a platform for collaboration and new initiatives. See Fig. 1. | other | 99.94 |
Although this is a difficult task, it may be more easily facilitated by the involvement of national surgical professional bodies. Professional bodies are well-respected by surgical healthcare providers and have a sense of academic activities happening within a country or region, so they have the ability and capacity to call for and organize information on global surgery efforts. As these bodies are not affiliated with any particular institution, they serve as an impartial resource for centralizing data and information, so surgical healthcare providers may be more willing to share information about their global surgery work. | other | 99.94 |
More time should be spent reflecting on work related to ISTCs. After any on-the-ground experiences within an ISTC, there should be an open meeting to reflect on what worked well and what did not, as well as other lessons learned. These lessons from previous experiences can be applied to future work to improve efficacy. Integral to this process is the involvement of local stakeholders, such as surgeons, nurses, and other healthcare providers, who can provide constructive feedback on the elements of the partnership that are going well and those that are not. For example, Human Resources for Health in Rwanda has gained valuable insight from introspective reflection of their program’s growth . Additionally, many participants had also reported that people who would consider becoming involved in ISTCs remain unaware of their options for participation. Reflection meetings could not only improve collaborations, but could increase the number of participants, which could help advance global surgery efforts . | other | 99.9 |
On a much larger scale, there should be involvement of and alignment with in-country stakeholders such as the Ministry of Health, Ministry of Finance, etc. who can lend support to ISTCs, direct resources to the areas of most need, and guide where efforts are implemented. This could potentially take form as an expansive country-wide conference that includes all HIC teams involved in the region as well as all local stakeholders to reflect on the coordination of efforts and how best to address the country’s needs. More recently, conferences such as these have been held in countries such as Zambia and India, leading to collective involvement of surgical healthcare providers and national stakeholders in discussing each country’s surgical needs and ways to address them . These conferences are often organized and hosted through the collective efforts of both LMIC and HIC stakeholders, including surgical healthcare providers and the Ministry of Health, as part of the implementation of national surgical, obstetric, and anesthesia plans . | other | 99.9 |
Ultimately, any form of reflection on ISTCs and their progress can better facilitate communication amongst involved parties, as well as facilitate coordination and collaboration amongst current efforts. By involving local surgical healthcare providers and national stakeholders, information from the local level can drive learning while being integrated at the national level to reflect on the progress of the country overall. This can help direct the work of ISTCs and better unify efforts. See Fig. 2. | other | 99.94 |
Subsets and Splits