Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis

Correlation of Pediatric Surgical Infrastructure With Clinical and Economic Outcomes: A Cohort Study

INTRODUCTION

A significant burden of unmet pediatric surgical disease exists in low- and middle-income countries. We sought to assess the associations between the installation of a pediatric operating room (OR) and clinical and economic outcomes for families with children in Ethiopia.

METHODS

A retrospective cohort study was performed of children who underwent elective surgery in a tertiary-level Ethiopian public hospital, comparing patient outcomes before and after OR installation in August 2019. Clinical data were collected via chart review, and an inpatient economic survey was administered to patient caregivers. Interrupted time series analysis investigated trends in surgical volume over time. The relative economic benefit was determined by comparing the patients' household income to the monetary health benefit gained using the value of statistical life method.

RESULTS

One thousand one hundred and ninety-six patients were included from August 2018 to July 2022. Surgery averted 20,541 disability-adjusted life years (DALYs) cumulatively or 17 DALYs per patient. Monthly case volume and DALYs averted significantly increased postinstallation. The median annual household income of the economic survey responders (n = 339) was $1337 (IQR 669-2592). 27.7% (n = 94/339) lived in extreme poverty, and 41.3% (n = 140/339) experienced catastrophic healthcare expenditure. Net monetary health benefit was $29.3 million or $26,646 per patient. The ratio of net monetary health benefit to household annual income was 60:1.

CONCLUSIONS

Installing a pediatric OR in a public Ethiopian hospital ensures increased access to surgery for those most impoverished in Ethiopia and improves equitable access to surgical care. Greater investment in expanding pediatric surgical infrastructure can help address global inequities in child health.

Preintervention Wait Time and Survival in People With Rheumatic Heart Disease in Uganda

BACKGROUND

There is an unmet surgical burden among people living with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to first intervention and preoperative mortality are poorly understood.

METHODS

Individuals with RHD who met indications for valve surgery were identified using the Uganda National RHD Registry (January 2010-August 2022). Kaplan-Meier estimates and multivariable Cox proportional hazard models were used.

RESULTS

Of the cohort with clinical RHD, 64% (1452 of 2269) met criteria for an index operation. Of those, 13.5% obtained a surgical intervention, whereas 30.6% died before the operation. The estimated likelihood of first operation was 50% at 9.3 years of follow-up (95% CI, 8.1-upper limit not reached). Intervention was more likely in men vs women (hazard ratio [HR], 1.78; 95% CI, 1.21-2.64), those with postsecondary education vs primary school or less (HR, 3.60; 95% CI, 1.88-6.89), and those with a history of atrial fibrillation (HR, 2.78; 95% CI, 1.63-4.76). Surgical intervention was less likely for adults vs those aged <18 years (HR, 0.49; 95% CI, 0.32-0.77) and those with New York Heart Association Functional Class III/IV vs I/II (HR, 0.51; 95% CI, 0.32-0.83). The median preoperative survival time among those awaiting first operation was 4.6 years (95% CI, 3.9-5.7 years). History of infective endocarditis, right ventricular dysfunction, pericardial effusion, atrial fibrillation, and having surgical indications for multiple valves were associated with increased probability of death.

CONCLUSIONS

Our analysis revealed a prolonged time to first surgical intervention and high preintervention death for RHD in Uganda, with factors such as age, sex, and education level remaining barriers to obtaining surgery.

Understanding the Burden of Pediatric Traumatic Injury in Uganda: A Multicenter, Prospective Study

INTRODUCTION

Traumatic injury is responsible for eight million childhood deaths annually. In Uganda, there is a paucity of comprehensive data describing the burden of pediatric trauma, which is essential for resource allocation and surgical workforce planning. This study aimed to ascertain the burden of non-adolescent pediatric trauma across four Ugandan hospitals.

METHODS

We performed a descriptive review of four independent and prospective pediatric surgical databases in Uganda: Mulago National Referral Hospital (2012-2019), Mbarara Regional Referral Hospital (2015-2019), Soroti Regional Referral Hospital (SRRH) (2016-2019), and St Mary's Hospital Lacor (SMHL) (2016-2019). We sub-selected all clinical encounters that involved trauma. The primary outcome was the distribution of injury mechanisms. Secondary outcomes included operative intervention and clinical outcomes.

RESULTS

There was a total of 693 pediatric trauma patients, across four hospital sites: Mulago National Referral Hospital (n = 245), Mbarara Regional Referral Hospital (n = 29), SRRH (n = 292), and SMHL (n = 127). The majority of patients were male (63%), with a median age of 5 [interquartile range = 2, 8]. Chiefly, patients suffered blunt injury mechanisms, including falls (16.2%) and road traffic crashes (14.7%) resulting in abdominal trauma (29.4%) and contusions (11.8%). At SRRH and SMHL, from which orthopedic data were available, 27% of patients suffered long-bone fractures. Overall, 55% of patients underwent surgery and 95% recovered to discharge.

CONCLUSIONS

In Uganda, non-adolescent pediatric trauma patients most commonly suffer injuries due to falls and road traffic crashes, resulting in high rates of abdominal trauma. Amid surgical workforce deficits and resource-variability, these data support interventions aimed at training adult general surgeons to provide emergency pediatric surgical care and procedures.

Challenges and lessons learnt in the management of an HIV-exposed neonate with gastroschisis in a resource-limited setting: case report

Introduction and importance

The incidence of congenital abdominal wall defects is increasing, but few cases have been reported in the African population.

Case presentation

The authors report a case of gastroschisis in a term neonate who was delivered through spontaneous vaginal delivery (SVD) in a remote health facility before transfer to a tertiary hospital in Uganda. Although there was no environmental exposure to teratogens, the major risk factor of Gastroschisis, the neonate was low birth weight, HIV-exposed, and the mother had not received folic acid supplementation during the first trimester, known risk factors of gastroschisis. Physical examination revealed intrauterine growth restriction in addition to the findings of the abdominal wall defect.

Clinical discussion

There were many missed opportunities in the management of this case which was marred by delayed essential care of the newborn, delayed surgical repair, and transfer to the tertiary surgical centre. At the tertiary surgical centre, a modified silo technique with delayed secondary closure was used to repair the defect, but the neonate still met its death before completing day 7 of life.

Conclusion

This case of gastroschisis shows how the diagnosis and management of neonates born with major congenital structural abnormalities in resource-limited settings is still desirable due to lack of sophisticated medical care services to assist in early detection during pregnancy and early surgical intervention at birth to prevent associated mortality. The authors discuss the lessons learnt and provide recommendations for improvement in the care of neonates born with abdominal wall defects and other congenital birth defects.

The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda

PURPOSE

The Pediatric Emergency Surgery Course (PESC) trains rural Ugandan providers to recognize and manage critical pediatric surgical conditions. 45 providers took PESC between 2018 and 2019. We sought to assess the impact of the course at three regional hospitals: Fort Portal, Kabale, and Kiwoko.

METHODS

We conducted a retrospective cohort study. Diagnosis, procedure, and patient outcome data were collected twelve months before and after PESC from admission and theater logbooks. We also assessed referrals from these institutions to Uganda's two pediatric surgery hubs: Mulago and Mbarara Hospitals. Wilcoxon rank-sum and Pearson's chi-squared tests compared pre- and post-PESC measures. Interrupted time-series-analysis assessed referral volume before and after PESC.

RESULTS

1534 admissions and 2148 cases were documented across the three regional hospitals. Kiwoko made 539 referrals, while pediatric surgery hubs received 116 referrals. There was a statistically significant immediate increase in the number of referrals from Fort Portal, from 0.5 patients/month pre-PESC to 0.8 post-PESC (95 % CI 0.03-1.51). Moving averages of the combined number of pyloromyotomy, intussusception reductions, and hernia repairs at the rural hospitals also increased post-course. Neonatal time to referral and referred patient age were significantly lower after PESC delivery.

CONCLUSION

Our data suggest that PESC increased referrals to tertiary centers and operative volume of selected cases at rural hospitals and shortened time to presentation at sites receiving referrals. PESC is a locally-driven, validated, clinical education intervention that improves timely care of pediatric surgical emergencies and merits further support and dissemination.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE

III.