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BACKGROUND: Surgery has had low priority in global health planning, so the delivery of surgical care in low- and middle-income countries is often poorly resourced. A recent Lancet Commission on Global Surgery has highlighted the need for change. METHODS: A consensus view of the problems and solutions was identified by individual surgeons from high-income countries, familiar with surgical care in remote and poorer environments, based on recent publications related to global surgery. RESULTS: The major issues identified were: the perceived unimportance of surgery, shortage of personnel, lack of appropriate training and failure to establish surgical standards, failure to appreciate local needs and poor coordination of service delivery. CONCLUSION: Surgery deserves a higher priority in global health resource allocation. Lessons learned from participation in humanitarian crises should be considered in surgical developments.

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BACKGROUND: Trauma systems have improved outcomes for injured patients, but might be challenging to implement. We assessed the implementation of a trauma system in Norway after recommendations for a national trauma system were published in 2007, with a focus on elements in acute care hospitals. METHODS: All hospitals in Norway, except for the four regional trauma centres, admitting injured patients at the time of the study were included in a telephone survey. The questionnaire was administered during May 2013 by the regional trauma coordinators who interviewed the local trauma coordinator and/or the local doctor responsible for trauma care in all the acute care hospitals. The main categories were availability of the trauma team and team training, written procedures, preparedness and training of personnel. The compliance to a set of 17 predefined trauma system criteria was evaluated at each institution. RESULTS: Of the 35 acute care hospitals in Norway admitting trauma patients at the time of the survey, all were included. The median number of fulfilled criteria was 14. Major deficiencies were found in fulfilling competence criteria, maintaining a local trauma registry, and trauma audits. The number of fulfilled criteria correlated strongly with the size of the hospital and the frequency of trauma team activation. CONCLUSIONS: Shortcomings in requirements for lower-level trauma care hospitals correlate to hospital size and frequency with which the trauma team is activated. In order to fulfill the minimum requirements, smaller hospitals should receive more attention.

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Nursing mothers are occasionally treated with intravenous lidocaine for ventricular dysrhythmias. There have been no reports on the excretion of lidocaine into breast milk. This case documents the excretion of lidocaine into breast milk in small amounts and shows the validity of the TDx methodology used in the whole-milk lidocaine assay. We observed breast-milk concentrations of lidocaine at 40 percent of the serum levels. Clinical practitioners should be aware the lidocaine is excreted into breast milk in small amounts and the mother could probably continue to safely breast-feed her child while on parenteral lidocaine. Any adverse reactions in the nursing infant would probably be limited to an idiosyncratic or allergic reaction.

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Kinetics of and clinical responses to N-acetylprocainamide (NAPA) were evaluated in 10 patients with chronic ventricular arrhythmias who had not responded to usual doses of currently available antiarrhythmic drugs. Kinetic data analysis was by measured NAPA concentrations (n = 149) collected during repeated dosing. Response was evaluated with serial 24-hr ambulatory ECGs. An a priori kinetic model based on earlier studies predicted NAPA concentrations well (r = 0.94, SEE = 3.6 mg/l). The capability for defining patient-specific estimates for drug disposition with six or seven serum concentrations measured at the outset of therapy was subsequently confirmed with larger data sets from the same patients. Mean values for elimination rate (0.082 hr -1 +/- 0.017) and volume of distribution (1.25 l/kg +/- 0.28) were of the same order as in earlier single-dose studies. A substantial degree of interpatient and intrapatient variability in the absorption rate for NAPA was observed. NAPA was not found to be clinically effective in any of the 10 patients, although two patients demonstrated a greater than 70% reduction in frequency of premature ventricular contractions. There were adverse effects in all patients, which frequently required dose reduction or cessation of therapy. In this group of patients with resistant arrhythmias, NAPA was no more effective than baseline therapy, and adverse effects often limited complete evaluation. The kinetic analysis demonstrated the feasibility of a strategy for developing patient-specific kinetic models that may have applications to other antiarrhythmic drugs.

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Three women, aged 27, 33, and 35 years, experienced recurrent syncope five months after losing 36 to 41 kg using liquid protein diets. No abnormalities were noted during physical examination except in one who was hypothyroid. Serum potassium levels varied between 2.9 and 3.9 mEq/liter. The ECGs demonstrated prominent U waves, QUc prolongation, and ST and T wave abnormalities, with left axis deviation in two patients. Syncopal episodes were due to ventricular tachycardia and fibrillation, which were not responsive to conventional antiarrhythmic agents used in two patients. Patients using liquid protein diets may thus experience reversible QUc prolongation giving rise to serious arrhythmias that are probably best treated with drugs that shorten the QTc interval. Caution should be exercised in the use of liquid protein diets for weight reduction in obesity.

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