Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation--other organisational, ethical, and political arguments can also be made for its inclusion.

Background. Within the developing world, many personal, sociocultural, and economic factors cause delayed patient presentation, a prolonged interval from initial symptom discovery to provider presentation. Understanding these barriers to care is crucial to optimizing interventions that pre-empt patient delay. Methods. A systematic review was conducted querying: PubMed, Embase, Web of Science, CINAHL, Cochrane Library, J East, CAB, African Index Medicus, and LiLACS. Of 763 unique abstracts, 122 were extracted for full review and 13 included in final analysis. Results. Studies posed variable risks of bias and produced mixed results. There is strong evidence that lower education level and lesser income status contribute to patient delay. There is weaker and, sometimes, contradictory evidence that other factors may also contribute. Discussion. Poverty emerges as the underlying common denominator preventing earlier presentation in these settings. The evidence for sociocultural variables is less strong, but may reflect current paucity of high-quality research. Conflicting results may be due to heterogeneity of the developing world itself. Conclusion. Future research is required that includes patients with and without delay, utilizes a validated questionnaire, and controls for potential confounders. Current evidence suggests that interventions should primarily increase proximal and affordable healthcare access and secondarily enhance breast cancer awareness, to productively reduce patient delay.

Compound muscle action potential amplitude predicts the severity of cubital tunnel syndrome.Background: Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone.Methods: A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment.Results: Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not. Conclusions:Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention.Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.Disclosure: There was no source of external funding for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article

Although sample concentration was a serious confounding factor, after correcting for dilution using the creatinine content, the elevated urinary levels of total beta-hCG indicated those T2-T4 lesions which were likely to metastasize and those patients likely to die early. If this test is to be used clinically, concentrated samples, i.e. early-morning urine, and a more sensitive beta-hCG assay are required. Nevertheless, for T2-T4 bladder tumours, an elevated pre-treatment level of urinary beta-hCG is a marker of poor prognosis and may prove useful in deciding appropriate therapy.

Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Maternal serum levels of human chorionic gonadotrophin and its subunits (intact, alpha, and free beta h CG) and pregnancy-associated plasma protein A (PAPP-A) were measured in 279 women between 8 and 14 weeks' gestation. This group included 23 pregnancies in which the fetus had Down syndrome (DS), diagnosed either at birth or during the second trimester (n = 17) or from chorionic villus sampling (CVS) (n = 6). Normal medians were determined from the 258 apparently normal pregnancies. The median levels of intact hCG (1.4 MOM) and free beta hCG (2.1 MOM) were significantly raised, whereas the median level of PAPP-A (0.39 MOM) was significantly lower in the DS pregnancies when compared with the control group. Levels of alpha hCG were similar in both the control and the DS pregnancies. Analysis of samples taken prior to 14 weeks' gestation demonstrated that only PAPP-A (0.34 MOM) was significantly altered in DS pregnancies. However, after the exclusion of DS cases diagnosed at CVS, the median intact hCG (1.56 MOM), free beta hCG (2.27 MOM), and alpha hCG (1.8 MOM) were all raised in DS pregnancies. This emphasizes the problem of the interpretation of biochemical markers when DS cases are diagnosed at CVS.

Background. In Haiti, breast cancer patients present at such advanced stages that even modern therapies offer modest survival benefit. Identifying the personal, sociocultural, and economic barriers-to-care delaying patient presentation is crucial to controlling disease. Methods. Patients presenting to the Hôpital Bon Sauveur in Cange were prospectively accrued. Delay was defined as 12 weeks or longer from initial sign/symptom discovery to presentation, as durations greater than this cutoff correlate with reduced survival. A matched case-control analysis with multivariate logistic regression was used to identify factors predicting delay. Results. Of N = 123 patients accrued, 90 (73%) reported symptom-presentation duration and formed the basis of this study: 52 patients presented within 12 weeks of symptoms, while 38 patients waited longer than 12 weeks. On logistic regression, lower education status (OR = 5.6, P = 0.03), failure to initially recognize mass as important (OR = 13.0, P < 0.01), and fear of treatment cost (OR = 8.3, P = 0.03) were shown to independently predict delayed patient presentation. Conclusion. To reduce stage at presentation, future interventions must educate patients on the recognition of initial breast cancer signs and symptoms and address cost concerns by providing care free of charge and/or advertising that existing care is already free.

Reflecting the growing understanding of vascular endothelial growth factor (VEGF) in cancer survival and growth, the anti-VEGF antibody bevacizumab (Avastin) is increasingly used to treat advanced malignancy. However, because VEGF also mediates proper wound healing, bevacizumab may lead to potentially severe wound-healing complications (WHCs). Because bevacizumab expands in use, the plastic surgeon will increasingly be entrusted to manage such WHCs successfully. Therefore, this review summarizes the pathophysiological evidence, systematically reviews the available clinical evidence, and provides management guidelines for bevacizumab-related WHCs. Bevacizumab produces WHCs by disrupting vasodilation, increased vascular permeability, and angiogenesis. Current clinical evidence suggests that bevacizumab may increase WHC risk. This risk seems higher with neoadjuvant than adjuvant bevacizumab use and may be decreased by extending the bevacizumab-surgery interval. Further research is required to quantify the exact bevacizumab-related WHC incidence and optimize the bevacizumab-surgery interval. We propose management guidelines for bevacizumab-related WHCs by indication that should be integrated with clinical judgment, input from the oncology team, and patient wishes when making therapeutic decisions.