ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures.SettingThe study was conducted at Timor Leste’s national referral hospital in Dili, the country’s capital.ParticipantsAll patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded.Primary and secondary outcome measuresData pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework.ResultsFifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05).ConclusionsSubstantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.

Background: Surgically treatable conditions are well documented in high-income countries. There is a gap in epidemiological understanding of breast pathology in many developing countries, Timor-Leste among them. This study was conducted to determine the burden of breast disease and to inform public health measures to address early detection, diagnosis and management. Methods: A retrospective quantitative case-control study was conducted at Guido Valadares National Hospital in Dili. Patients were included if they attended surgical outpatients or had a pathology specimen recorded between 1 September 2016 and 1 September 2017. Results: There were 444 female patients with a clinical diagnosis of breast disease over the 12-month period. The average age was 33.7 years. There were 188 (42.3% of total sample) cases of fibroadenoma and 122 (27.4% of total sample) diagnoses consistent with nonspecific lumps. Of the 116 female patients presenting to Guido Valadares National Hospital who had a biopsy, 62.6% were malignant or hyperplastic in nature, and 86% of those with a malignant biopsy had clinically locally advanced disease. Conclusion: Breast conditions including cancer in Timor-Leste are relatively common and occur in young women in the prime of their lives (37 years of age). Developing a national cancer registry and funding directed towards improving early presentation and good clinical care of breast cancer patients will be critical for reducing early morbidity and mortality and improving other patient outcomes including income loss, gender health inequality and the intergenerational effects of early parental death.

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Division, has been permitted to retire from the service from Dec. 3rd last. Colonel H. StClare Carruthers, Madras, has been selected for the appointment of Principal Medical Officer, Secunderabad Brigade. Lieutenant-Colonel J. C. Marsden, Madras, has been permitted to retire with effect from Feb. 10th. Lieutenant-Colonel R. J. Marks has had his leave extended. Major Clemesha has been appointed to officiate as Sanitary Commissioner, Bengal Presidency, vice Lieutenant-Colonel Clarkson, proceeding on two years' combined leave and furlough out of India. Major C. M. Matthews has had his leave extended by six months Major Graves has been posted for temporary duty in the Madras Presidency. Major J. Davidson, in charge of the Dehra Dun Brigade Laboratory, has been appointed a specialist in the prevention of disease from Dec. 10th last. Major G. T. Birdwood, on completion of a course of special duty in the Bacteriological Laboratories of the Institute of Preventive Medicine at Kasauli, has been appointed Civil Surgeon of Mussooree. Captain W. T. McCown has been permitted an extension of his leave by six months on medical certificate. Captain Husband has been posted to Burma. TERRITORIAL FORCE. Royal Army Medical Corpc, 3rd Northern General Hospital: Captain Archibald Young to be Major (dated April 18th, 1909). Major Archibald Young resigns his commission (dated Nov. 20th, 1909). Captain Arthur R. Hallam to be Major (dated Nov. 20th, 1909).