Summaryobjective To determine the incidence of specific surgical emergencies in a mountainous rural community in the Northern Areas of Pakistan and to assess use of existing health services, and outcomes related to acute surgical illness events.method A cross-sectional population-based survey was conducted. Interviewers visited each of 118 villages in the study area (population 100000), selected a random sample from a total of 9900 households, and interviewed the oldest premenopausal female member (n ϭ 836). Questions were focused on injury, acute abdomen, and/or maternal morbidity occurring in the past year. Cases were included as surgical emergencies when one or more index clinical features indicating a potential for surgical intervention were present. Mortality from a wider range of surgical emergencies was also elicited based on the respondent's lifetime knowledge of the household.results The incidence rates were 1531/100000 persons per year for injuries; 1364/100000 for acute abdomen, and 16462/100 000 for maternal morbidity. The rate of injuries was 2.7 times higher and that of acute abdomen twice as high in males as in females. The injury rate decreased with advancing age, being 13 times higher in children Ͻ 5 years than in adults Ͼ 40. By contrast, the rate for acute abdomen showed a rise with advancing age, being 8 times higher in the Ͼ 40 age group than in under-fives. Burns, falls and road accidents, in that order, were the commonest forms of injury accounting for 82% of 138 cases. Of 43 burn casualties, 46% were in the age group Ͻ 5 years; there was no gender bias. Of 71 casualties from falls and road accidents, 85% were aged 6-40 years; there was 6 : 1 male predominance. The maternal morbidity rate was highest in the age group 25-35 years and may be attributed to the high pregnancy rate in this age bracket. Of 408 patients with acute surgical illness, 85% were managed initially at home or close to home in a health centre, dispensary or civil hospital; 32% eventually sought specialist surgical care. The overall rate for minor and major surgical procedures was 411/100000 persons per year (lowest estimate), and appeared to be low. The rate of operative deliveries at 11.8/1000 deliveries (lowest estimate) was particularly low. The mortality rates were correspondingly high: 55/100000 persons per year for injuries and for acute abdomen (lowest estimates). The maternal mortality ratio was particularly high at 8.9/1000 deliveries (lowest estimate). Annual mortality rates derived from deaths recalled during the respondent's lifetime in the household (mean period ϭ 26 years), tended to corroborate the results of the 1-year survey.conclusion The incidence rates for broad categories of serious acute surgical illness in the study population far exceeded the rates of acute surgical intervention. Mortality rates were correspondingly high. Such evidence points to a large unmet surgical need and ought to spur improvements in the health service.

BackgroundAga Khan University is developing its undergraduate medical education curriculum for East Africa. In Kenya, a 1 year internship is mandatory for medical graduates’ registration as practitioners. The majority of approved internship training sites are at district hospitals. The purposes of this study were to determine: (1) whether recent Kenyan medical graduates are prepared for their roles as interns in district hospitals upon graduation from medical school; (2) what working and training conditions and social support interns are likely to face in district hospital; and (3) what aspects of the undergraduate curriculum need to be addressed to overcome perceived deficiencies in interns’ competencies.MethodsFocus group discussions and semi-structured interviews were conducted with current interns and clinical supervisors in seven district hospitals in Kenya. Perceptions of both interns and supervisors regarding interns’ responsibilities and skills, working conditions at district hospitals, and improvements required in medical education were obtained.ResultsFindings included agreement across informants on deficiencies in interns’ practical skills and experience of managing clinical challenges. Supervisors were generally critical regarding interns’ competencies, whereas interns were more specific about their weaknesses. Supervisor expectations were higher in relation to surgical procedures than those of interns. There was agreement on the limited learning, clinical facilities and social support available at district hospitals including, according to interns, inadequate supervision. Supervisors felt they provided adequate supervision and that interns lacked the ability to initiate communication with them. Both groups indicated transition challenges from medical school to medical practice attributable to inadequate practical experience. They indicated the need for more direct patient care responsibilities and clinical experience at a district hospital during undergraduate training.ConclusionPerception of medical graduates’ unpreparedness seemed to stem from a failure to implement the apprenticeship model of learning in medical school and lack of prior exposure to district hospitals. These findings will inform curriculum development to meet stakeholder requirements, improve the quality of graduates, and increase satisfaction with transition to practice.

On-site surveys of 19 district-level hospitals in Pakistan revealed that, in 1983, 23,839 procedures were performed. There were 98 different types of operations. Thirty-eight per cent were classified as General Surgery, 30 per cent Gynecology and Operative Obstetrics, 19 per cent Urology, and 13 per cent Orthopedics.In three regions, population-based data were obtained from the 12 hospitals which provided all surgical care to discrete populations. The overall rate of surgical operations per 100,000 population was 124, 1.5 per cent to 9 per cent of the rate in western countries. The

We feel that these results confirm the theory that echocardiography, as currently provided, significantly delays surgery for hip fracture and that this may negatively affect patient outcomes.