Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District

Adaptation and validation of the Children's Surgical Assessment Tool for Rwandan district hospitals

BACKGROUND/AIMS

Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda.

METHODS

We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool.

RESULTS

The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research.

CONCLUSION

The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Optimal content for a surgical curriculum for general practice in Rwanda: A Delphi study

BACKGROUND

In Rwanda, a nationwide shortage of surgeons necessitates general practitioners (GPs) perform many common procedures and minor surgeries. However, GPs only receive a 1-year internship to prepare them to provide this care. We performed a Delphi survey of practicing GPs to assess essential content for a surgical curriculum for Rwandan interns to better prepare them for general practice.

METHODS

We invited 56 practicing GPs to participate in a two-round anonymous electronic survey in February 2023. The first round assessed demographics and solicited free-text responses to gather knowledge and procedural content suggestions for the curriculum. The second round refined these responses into key content areas.

RESULTS

Thirty-one GPs responded to both rounds of the Delphi survey. They provided insight into the most commonly performed procedures, most important technical skills, and the top areas of surgical knowledge necessary for general practice. They expressed a need for more exposure to a variety of surgical pathologies and interventions across multiple specialties, highlighting the value of foundational skills in trauma, obstetrics and gynecology, and orthopedics, both at the beginning of their internship, as well as at the beginning of their general practice.

CONCLUSIONS

GPs emphasized the importance of broad exposure to common acute surgical pathology and interventions across several surgical subspecialties, as well as a need for foundational technical skills and surgical knowledge. The results of our study underscore the necessity of a surgical education providing a solid basis in the foundational knowledge and techniques of surgical care.

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda

Introduction/Background

Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda.

Methods

We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains.

Results

None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance).

Conclusions

This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

Pediatric Surgical Waitlist in Low Middle Income Countries during the COVID-19 Pandemic

Purpose

COVID-19 led to significant reduction in surgery worldwide. Studies, however, of the effect on surgical volume for pediatric patients in low- and middle-income countries (LMICs) are limited.

Methods

A survey was developed to estimate waitlists in LMICs for priority surgical conditions in children. The survey was piloted and revised before it was deployed over email to 19 surgeons. Pediatric surgeons at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey from February 2021 to June 2021. The survey included the total number of children awaiting surgery and estimates for specific conditions. Respondents were also able to add additional procedures.

Results

Public hospitals had longer wait times than private facilities. The median waitlist was 90 patients and the median wait time was 2 months for elective surgeries.

Conclusion

Lengthy surgical wait times affect surgical access in LMICs. COVID-19 had been associated with surgical delays around the world, exacerbating existing surgical backlogs. Our results revealed significant delays for elective, urgent and emergent cases across Sub-Saharan Africa. Stakeholders should consider approaches to scale the limited surgical and perioperative resources in LMICs, create mitigation strategies for future pandemics, and establish ways to monitor waitlists on an ongoing basis.

Challenges with pediatric surgical financing and universal health coverage in Guatemala: A qualitative analysis

The financing of surgical care for children in low- and middle-income countries (LMICs) remains challenging and may restrict adherence to universal health coverage (UHC) frameworks. Our aims were to describe Guatemala's national pediatric surgical financing structure, to identify financing challenges, and to develop recommendations to improve the financing of surgical care for children. We conducted a qualitative study of the financing of surgical care for children in Guatemala's public health system with key informant interviews (n = 20) with experts in the medical, financial, and political health sectors. We used this data to generate recommendations to improve surgical care financing for children. We identified several systemic challenges to the financing of surgical care for children, including passive purchasing structures, complex political contexts, health system fragmentation, widespread use of informal fees for surgical services, and lack of earmarked funding for surgical care. Patient and provider challenges include lack of provider input in non-personnel funding decisions, and patients functioning as both financing agents and beneficiaries in the same financing stream. Key recommendations include reducing health finance system fragmentation through resource pooling, increasing earmarked funding for surgical care with quantifiable outcome measures, engagement with clinical providers in non-personnel budgetary decision-making, and use of innovative financing instruments such as resource pooling. Surgical financing for children in Guatemala requires substantial remodeling to increase access to timely, affordable, and safe surgical care and improve alignment with Guatemala's UHC scheme.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone

Background

Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic.

Methods

This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members.

Results

A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4–7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery.

Conclusion

PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013–2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06695-7.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Paediatric surgical conditions in Malawi - A cross-sectional nationwide household survey

Background

Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce long-term effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need.

Aim

To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries.

Methods

A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection.

Results

There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region.

Conclusion

An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care.

Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa

OBJECTIVE

The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years.

RESULTS

Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality.

CONCLUSIONS

Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.

Bringing specialist paediatric surgical care to the doorstep in rural Ghana: A mobile paediatric surgery clinic

BACKGROUND

The contribution of paediatric surgical conditions to the total burden of disease in low- and middle-income countries (LMICs) has recently been highlighted and it is widely agreed that solutions are needed to provide access to safe and affordable surgery for these children.

MATERIALS AND METHODS

We present a simple, cost-effective model that brings paediatric surgery to the doorstep of remote areas and uses the existing health system structure in its entity to fulfil patients' needs. Mobile clinic teams whose members are integrated staff in affiliated mission hospitals reach out daily on a rotational basis to 10 health posts. The team receives continuous paediatric surgery education from a paediatric surgeon to diagnose and treat simple cases.

RESULTS

The catchment area of the Gye Nyame Mobile Clinic includes 832,984 inhabitants. From 2008 to 2019, 4362 children visited the mobile clinic with a median age of 4.41 years. Totally 4142 (95.0%) children could be treated in the health post, 150 (3.4%) children were taken to the affiliated missionary hospitals, 55 (1.3%) needed a third-level facility and 15 (0.3%) were taken to the traditional healers by the family. The common paediatric surgical diagnosis on outreach was deep soft-tissue infection/skin lesion for surgical treatment (672/23.8% children), followed by abdominal wall hernia/abdominal wall malformation (586/20.8% children) and gastrointestinal conditions (521/18.5%).

CONCLUSION

This model of paediatric surgery mobile clinic includes capacity-building, task-sharing, outreach and proven 12-year sustainability. We recommend this model for paediatric surgery care in remote areas of LMIC's.

Presentation of Pediatric Unintentional Injuries at Rural Hospitals in Rwanda: A Retrospective Study

Background:

Injuries are a leading cause of mortality among children globally, with children in low- and middle-income countries more likely to die if injured compared to children in high-income countries. Timely and high-quality care are essential to reduce injury-related morbidity and mortality.

Objectives:

This study describes patterns, management, and outcomes of children 0–15 years presenting with unintentional injuries at three district hospitals in rural Rwanda between January 1 and December 31, 2017.

Methods:

Using a retrospective cross-sectional study design, we assessed the demographic and clinical characteristics, care provided, and outcomes of the children using data extracted from patient medical charts. We describe the patient population using frequencies and proportions as well as median and interquartile ranges.

Findings:

Of the 449 injured children who sought care at the three rural district hospitals, 66.2% (n = 297) were boys. The main causes of injury were falls (n = 261, 58.1%), burns (n = 101, 22.5%), and road traffic injuries (n = 67, 14.9%). Burns were the most common injury among children aged 0–5 years while falls were the leading injury type among the 5–15 years age group. Vital signs were inconsistently completed ranging between 23.8–89.1% of vital sign items. Of the injured children, 37.0% (n = 166) received surgery at the district hospital, general practitioners performed 80.9% (n = 114) of surgeries, 87.4% (n = 145) of operated patients received no anesthesia, and 69.3% (n = 311) were admitted to the district hospital, while 2.7% (n = 12) were transferred to tertiary facilities for higher-level care.

Conclusions:

The presentation of child injuries—namely falls, burns, and road traffic accidents—is similar to what has been reported in other sub-Saharan African countries. However, more needs to be done to improve the completion and documentation of vital signs and increase availability of surgical specialists. Finally, targeted strategies to prevent burns and motorcycle-related injuries are recommended prevention interventions for this rural population.

Developing Metrics to Define Progress in Children's Surgery

There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.

The Impact of Social Stigma for Children with Cleft Lip and/or Palate in Low-resource Areas: A Systematic Review

There are still children with cleft lip and/or palate (CLP) in low-resource areas who face social rejection. This stigma disadvantages children in education, employment, marriage, and community, and is exacerbated by barriers to care. Our study objective was to conduct a systematic review of the impact of social stigma of CLP for children in low-resource areas. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A systematic search was conducted of 3 databases: Ovid Embase, Ovid Medline, and the African Journal Online from 2000 to October 5 2018. Common themes were identified using a grounded theory approach and quantitatively summarized. The Joanna Briggs Institute criteria were used to evaluate the risk-of-bias assessments. Four hundred seventy-seven articles were screened; 15 articles were included that focused on the impact of social stigma on CLP in low-resource areas. This was limited to English articles. The majority of studies originated in Nigeria or India. Themes were reported as follows: societal beliefs (n = 9; 60%), social impact (n = 7; 46%), marriage (n = 7; 46%), education (n = 6; 40%), employment (n = 5; 33%), and psychological distress (n = 3; 20%). Causes include the effect of “God’s will,” supernatural forces, evil spirits or ancestral spirits, exposure to an eclipse, black magic, or a contagion. Further, children with CLP may not be worth a full name or considered human and killed. Awareness of the impact of social stigma for children with CLP in low-resource areas generates support toward national education and awareness in low-resource areas.

The Prevalence and Characteristics of Untreated Hernias in Southwest Cameroon

BACKGROUND

Hernias are one of the most commonly encountered surgical conditions, and every year, more than 20 million hernia repairs are performed worldwide. The surgical management of hernia, however, is largely neglected as a public health priority in developing countries, despite its cost-effectiveness. To date, the prevalence and impact of hernia have not been formally studied in a community setting in Cameroon. The aim of this study was to determine the prevalence and characteristics of untreated hernia in the Southwest region of Cameroon.

METHODS

This study was a subanalysis of a cross-sectional community-based survey on injury in Southwest Cameroon. Households were sampled using a three-stage cluster sampling method. Household representatives reported all untreated hernias occurring in the past year. Data on socioeconomic factors, hernia symptoms, including the presence of hernia incarceration, and treatment attempts were collected between January 2017 and March 2017.

RESULTS

Among 8065 participants, 73 persons reported symptoms of untreated hernia, resulting in an overall prevalence of 7.4 cases per 1000 persons (95% confidence limit 4.98-11.11). Groin hernias were most commonly reported (n = 49, 67.1%) and predominant in young adult males. More than half of persons with untreated hernia (56.7%) reported having symptoms of incarceration, yet 42.1% (n = 16) of these participants did not receive any surgical treatment. Moreover, 21.9% of participants with untreated hernias never presented to formal medical care, primarily because of the high-perceived cost of care. Untreated hernias caused considerable disability, as 21.9% of participants were unable to work because of their symptoms, and 15.1% of households earned less money.

CONCLUSIONS

Hernia is a significant surgical problem in Southwest Cameroon. Despite over half of those with unrepaired hernias reporting symptoms of incarceration, home treatment and nonsurgical management were common. Costs associated with formal medical services are a major barrier to obtaining consultation and repair. Greater awareness of hernia complications and cost restructuring should be considered to prevent disability and mortality due to hernia.

Incidence and prevalence of congenital anomalies in low- and middle-income countries: A systematic review

BACKGROUND

In the absence of robust data from low- and middle-income countries (LMICs), most disease burden estimates and related resource allocation choices are based on historic Northern demographics. We hypothesize that significant discrepancies exist between directly reported LMIC data and surrogate high-income country (HIC) disease burden estimates of correctible congenital anomalies.

METHODS

Nine online databases were searched for studies reporting incidence and prevalence data on surgically correctible congenital anomalies in LMICs between 2006 and 2017. Two independent reviewers screened titles and abstracts, with a third adjudicating discrepancies. Selected studies were reviewed and analyzed.

RESULTS

Of 10,128 identified articles, 98 were extracted for full-text review, and 41 were included, representing 21 LMICs and 18 conditions. Study types included community surveys (34%), prospective (22%) and retrospective (17%) multi-site data, registries (12%), single-site data (12%), and systematic reviews (5%). Data collection periods were 1 to 10 years. The pooled epidemiologic data varied systematically from existing HIC literature, with the incidence of disease being generally lower in LMICs.

CONCLUSIONS

Marked discrepancies exist between reported epidemiological data in LMICs and HIC literature, in part owing to varying quality of data collection in LMICs. Robust population-based surveys are needed to accurately estimate the burden of surgically correctable congenital anomalies in LMICs.

LEVEL OF EVIDENCE

Level V, expert opinion without explicit critical appraisal.

Growing research in global surgery with an eye towards equity

Background

Global surgery research is often generated through collaborative partnerships between researchers from both low- and middle-income countries (LMICs) and high-income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research.

Methods

This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda.

Results

Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding.

Conclusion

It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement.

Prevalence of Pediatric Surgical Conditions Across Somaliland

IMPORTANCE

Although surgical conditions are increasingly recognized as causing a significant health care burden among adults in low- and middle-income countries (LMICs), the burden of surgical conditions among children in LMICs remains poorly defined.

OBJECTIVE

To estimate the prevalence of pediatric surgical conditions across Somaliland using a nationwide community-based household survey.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted through a national community-based sampling survey from August through December 2017 in Somaliland. Participants were 1503 children surveyed using the Surgeons OverSeas Assessment of Surgical Need (SOSAS).

MAIN OUTCOMES AND MEASURES

The SOSAS survey contains 2 components, including a section on household demographics, deaths, and financial information and sections querying children's history of surgical conditions.

RESULTS

In this cross-sectional study that included 1503 children (55.6% male; mean [SE] age, 6.4 [0.1] years), 221 surgical conditions were identified among 196 children, yielding a mean (SE) prevalence of pediatric surgical conditions of 12.2% (1.5%). Only 53 of these 221 surgical conditions (23.7%) had been surgically corrected at the time of the survey. The most common conditions encountered were congenital anomalies (33.8%) and wound-related injuries (24.6%). Nationally, an estimated 256 745 children have surgical conditions, with an estimated 88 345 to 199 639 children having unmet surgical needs.

CONCLUSIONS AND RELEVANCE

Using national sampling, this study found that children have a high burden of surgical conditions in Somaliland. These data highlight the need for a scale-up of pediatric surgical infrastructure and resources to provide the needed surgical care for children in LMICs.

Factors associated with complex surgical wounds in breast and abdomen: a case-control observational study

OBJECTIVE

to identify factors associated with complex surgical wounds in the breasts and abdomen in outpatients.

METHOD

observational case-control study involving 327 patients, distributed into 160 cases (complex surgical wound) and 167 controls (simple surgical wound). Data were extracted from the medical records and a binary logistic regression model was used for analysis, considering a significance level of 5%.

RESULTS

the factors associated with greater chance of occurrence of complex surgical wound were 18 to 59 years of age (p = 0.003), schooling < 8 years (p = 0.049), radiotherapy (p < 0.001), hysterectomy (p = 0.003), glycemia (≤ 99 mg/dL) and arterial hypertension (p = 0.033), while quadrantectomy (p = 0.025) served as a protective factor.

CONCLUSION

radiotherapy was the most significant factor for surgical wound complications. Glycemic alteration was an unexpected result and shows the need for further studies related to this topic.