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Gajewski J, Pittalis C, Borgstein E, Bijlmakers L, Mwapasa G, Cheelo M, Juma A, Sardana M, Brugha R. Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania. Front Pediatr 2023; 11:1189676. [PMID: 37325346 PMCID: PMC10265866 DOI: 10.3389/fped.2023.1189676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Methods Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Results Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. Conclusions With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.
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Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric Borgstein
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Leon Bijlmakers
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Mweene Cheelo
- Surgical Society of Zambia, University Teaching Hospital Lusaka, Lusaka, Zambia
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Muskan Sardana
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Nuss S, Cahill GL, Limenh W, Wiedermann J. Developing Consensus on Priority Pediatric Otolaryngology-Head and Neck Surgery Conditions and Procedures. Otolaryngol Head Neck Surg 2023. [PMID: 36939625 DOI: 10.1002/ohn.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/30/2022] [Accepted: 01/21/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to develop an international expert consensus on priority pediatric otolaryngology-head and neck surgery (OHNS) conditions and procedures for which all national health systems globally should be capable of managing. STUDY DESIGN The Delphi method is a multiround online questionnaire and was administered internationally to otolaryngologists with a focus on pediatric populations. This study was administered in parallel to a Delphi survey focusing on adult OHNS conditions amongst adult otolaryngology experts. SETTING International online survey. METHODS In round 1, participants listed the top 15 pediatric otolaryngological conditions and top 15 pediatric otolaryngology procedures for their World Bank region. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as at least 70% of the round 2 Likert responses being ranked as either "important" or "very important." Descriptive statistics were calculated for each round. RESULTS The survey was distributed to 35 experts globally, with a 40% (n = 14) response rate. Fifty percent (n = 7) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. A list of 28 consensus surgical procedures and 11 consensus conditions were identified. CONCLUSION This Delphi survey method of world experts in pediatric otolaryngology identified a core list of medical conditions and surgical procedures that should be a part of every national health system's clinical goals of treatment, research, and capacity building.
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Affiliation(s)
- Sarah Nuss
- Global Otolaryngology-Head and Neck Surgery Initiative, Boston, Massachusetts, USA.,Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Gabrielle L Cahill
- Global Otolaryngology-Head and Neck Surgery Initiative, Boston, Massachusetts, USA.,University of California Los Angeles Department of Head and Neck Surgery, Los Angeles, California, USA
| | - Wale Limenh
- Global Otolaryngology-Head and Neck Surgery Initiative, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, St. Paul Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Joshua Wiedermann
- Global Otolaryngology-Head and Neck Surgery Initiative, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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3
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Postgraduate Surgical Education in East, Central, and Southern Africa: A Needs Assessment Survey. J Am Coll Surg 2023; 236:429-435. [PMID: 36218266 DOI: 10.1097/xcs.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle-income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted. STUDY DESIGN The American College of Surgeons Operation Giving Back, in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within 5 domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback. RESULTS One-hundred sixty-six responses were received after 3 calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development. CONCLUSIONS This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region.
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Woods A, Shofner C, Hodge B. International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review. Glob Health Action 2022; 15:2111780. [PMID: 36047712 PMCID: PMC9448389 DOI: 10.1080/16549716.2022.2111780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Sub-Saharan Africa (SSA) faces a critical shortage of pediatric surgical providers. International partnerships can play an important role in pediatric surgical capacity building but must be ethical and sustainable. Objective The purpose of this study is to perform a scoping literature review of international pediatric surgery partnerships in SSA from 2009 to 2019. We aim to categorize and critically assess past partnerships to aid in future capacity-building efforts. Methods We performed a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. We searched the PubMed and Embase databases for articles published from 2009 to 2019 using 24 keywords. Articles were selected according to inclusion criteria and assessed by two readers. Descriptive analyses of the data collected were conducted in Excel. Results A total of 2376 articles were identified. After duplicates were removed, 405 articles were screened. In total, 83 articles were assessed for eligibility, and 62 were included in the review. The most common partnership category was short-term surgical trip (28 articles, 45%). A total of 35 articles (56%) included education of host country providers as part of the partnership. Only 45% of partnerships included follow-up care, and 50% included postoperative outcomes when applicable. Conclusions To increase sustainability, more partnerships must include education of local health-care providers, and short-term surgical trips must be integrated into long-term partnerships. More partnerships need to report postoperative outcomes and ensure follow-up care. Educating peri-operative providers, training general surgeons in common pediatric procedures, and increasing telehealth use are other goals for future partnerships.
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Affiliation(s)
- Alison Woods
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Charles Shofner
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bethany Hodge
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Global Education Office, University of Louisville School of Medicine, Louisville, KY, USA
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Abstract
More than two thirds of the global population lack access to safe, affordable surgical and anesthesia care. This inequity disproportionately affects children in low- and middle-income countries (LMIC). In 2016, a group of pediatric surgical care providers founded the Global Initiative for Children's Surgery (GICS). Their goal was to assemble a multidisciplinary team of specialists and advocates to improve surgical care for children, with a particular emphasis on those in low-resource settings. This review details the history of GICS, the process of its inception, the values guiding its work, its past achievements, and its current initiatives. The experience of GICS may serve as an effective model for global collaboration on other areas of public and global health.
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Maia VO, Pavarino E, Guidio LT, de Souza JPD, Ruano R, Schmidt AF, Fabbro ALD, Sbragia L. Crossing birth and mortality data as a clue for prevalence of congenital diaphragmatic hernia in Sao Paulo State: A cross sectional study. LANCET REGIONAL HEALTH. AMERICAS 2022; 14:100328. [PMID: 36777389 PMCID: PMC9903978 DOI: 10.1016/j.lana.2022.100328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background Congenital diaphragmatic hernia (CDH) is a severe embryological defect that causes pulmonary hypoplasia and hypertension. The prevalence and mortality rate of CDH varies around the world and little information is available about CDH in Latin America. Our aim was to estimate the general prevalence, mortality rate, prevalence of associated anomalies and features related to the outcomes of CDH in newborns from São Paulo state, Brazil. Methods Population-based cross-sectional study based on data gathered from the Live Births Information System (SINASC) and the Mortality Information System (SIM) of children born in São Paulo state between January 1st, 2006, and December 31st, 2017. Findings From 7,311,074 total survival discharges between 2006 and 2017, 1,155 were CDH-related, resulting in a prevalence rate of 1:6329 (95%CI = 1/6715 - 1/5984) and a mortality rate of 63·72% (95%CI = 60.95 - 66.50), 510 presented complex associated anomalies (44·15%). Maternal data showed higher prevalence among older mothers (older than 35 years old: 2·13 per 10,000) and, also, women with more years of schooling (higher than 12 years: 1·99 per 10,000). Presence of associated anomalies (95%CI = 5.69-11.10), 1-min Apgar (95%CI = 1.44-2.95), maternal schooling (95%CI = 1.06-2.43) and birth weight (95%CI = 1.04-2.26) were the most significant features associated with mortality. Interpretation There was 1 CDH case for every 6329 newborns in São Paulo and the mortality rate among those cases was 63·72% - a high rate compared to other countries. Funding This study didn't receive any specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Affiliation(s)
- Victoria Oliveira Maia
- Division of Pediatric Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Eduardo Pavarino
- Division of Pediatric Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Leandro Tonderys Guidio
- Medical School of Bauru, School of Dentistry, University of São Paulo (USP), Bauru, São Paulo, Brazil
| | - João Paulo Dias de Souza
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Ruano
- Department of Pediatrics and Department of Obstetrics, Gynecology and Reproductive Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Augusto Frederico Schmidt
- Department of Pediatrics and Department of Obstetrics, Gynecology and Reproductive Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amaury Lelis Dal Fabbro
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Lourenço Sbragia
- Division of Pediatric Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil,Corresponding author at: Division of Pediatric Surgery, Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao Paulo. Av. Bandeirantes 3900 - Monte Alegre, Ribeirão Preto, SP Zipcode: 14049-900, Brazil.
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7
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Abstract
UNLABELLED Over the course of approximately 60 years, the field of pediatric urology has evolved as a convergence of pediatric surgery, urology, and plastic surgery to address congenital anomalies of the urinary tract and genitalia in children. Guidelines for training and certification are narrowing in high-income countries (HICs) at the same time as the fertility rate is declining and the prevalence of complex genitourinary (GU) conditions is decreasing. In low-and middle-income countries (LMICs), health systems for large populations are currently in a state of stress. Here we briefly review the history of pediatric urology as a surgical subspecialty, identify unmet needs especially in LMICs and place the field in the context of a global surgical ecosystem. METHODS The English language literature on workforce trends in pediatric urology, pediatric surgery and urology was reviewed as well as development of the emerging field of global surgery. Global surgery looks at the social, economic and political context of health systems as well as unmet clinical need. World trends in fertility rates were reviewed to identify regions of workforce surplus and gaps, supply chain needs, infrastructure and systems strengths and weaknesses. RESULTS The proliferation of training programs in pediatric surgery and specialties in high-income countries (HICs) coupled with declining birth rates has led to a saturation of specialists and declining surgical case load. In LMICs, while the birth rate has also been declining, surgical specialization has not progressed. In the lowest income countries, especially in sub-Saharan Africa, training in pediatric surgical specialties and urology is rare. The broad workforce that supports surgical care, such as anesthesia, intensivist pediatrics, radiology, laboratory, and nursing face similar challenges. Supply chains for specialized pediatric urological surgery are weak. CONCLUSION There is an evolving maldistribution of pediatric surgical and pediatric urological workforce globally, with too few practitioners in LMICs and too many in HICs. The high cost of specialized equipment limits access to quality care, and the supply chain for consumables and medication is patchy. In LIC's, basic community-based infrastructure for health including reliable electricity is lacking. Recent experience with Covid and environmental disasters has highlighted that even in HICs surgical resilience can be challenged. This is an opportunity to consider the state of children's urological care globally and to build resilience by identifying and addressing strengths and gaps.
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Affiliation(s)
- Catherine R deVries
- University of Utah School of Medicine, Center for Global Surgery, 30 N. 1900 E RM 3B110 SOM, Salt Lake City, UT 84132, USA.
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8
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Training low-middle-income (LMIC) pediatric surgeons in a high-income country (HIC) program. Pediatr Surg Int 2022; 38:269-276. [PMID: 34591153 DOI: 10.1007/s00383-021-05027-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. METHODS Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. RESULTS All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. CONCLUSION This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. LEVEL OF EVIDENCE V.
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9
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Tsang VWL, Luo LH, Kisa P, Blair GK. Ten Global Surgical Care Statements for Children: examining our commitment to the future. Pediatr Surg Int 2021; 37:957-964. [PMID: 33689002 DOI: 10.1007/s00383-021-04875-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lack of access to essential surgery for many of our world's children is a global health crisis. A third of all deaths in the pediatric population are due to surgical conditions. In low- and middle-income countries, an average of nine in ten children lack access to basic surgical care. METHODS This review examines ten commitment statements ratified by numerous global pediatric surgical organizations aimed at addressing existing gaps in global surgical care for children. They are substantiated by a review of literature and represent over-arching principles. RESULTS They prompt the recognition of childhood surgical disease as a global health priority and advocate for availability to safe surgical and anesthetic care. Calls to action highlight the importance of capacity building in the areas of education, data gathering, workforce, research, and international collaborations. DISCUSSION Eventually, there is the hope for widespread approval of the guiding principles they represent and that the statements themselves, as encapsulations of these beliefs, may act as a continued call for advocacy and action for the necessary work, resources, and funding to mitigate global pediatric surgical disparities.
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Affiliation(s)
- Vivian W L Tsang
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Lerly H Luo
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Phyllis Kisa
- Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda
| | - Geoffrey K Blair
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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10
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Kisa P, Scotland K, Afshar K, MacNeily AE. Surveying unmet pediatric urological needs in low- and middle-income countries. J Pediatr Urol 2021; 17:171.e1-171.e9. [PMID: 33546977 DOI: 10.1016/j.jpurol.2020.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 11/09/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Access to pediatric urological surgery is low in low-and-middle income countries (LMICs). Pediatric Urological missions have often been undertaken without best practice guidelines. Many strides have been made in pediatric general surgery and other surgery but little in pediatric urology as a component of global surgery. STUDY AIMS The purpose of this study was to identify challenges to delivery of pediatric urological care in LMICs and make recommendations for its advancement. STUDY DESIGN An internet search for reports and websites was undertaken. Published surveys from Global Initiative for Children Surgery (GICS) and American Pediatric Surgical Association (APSA) were evaluated. We developed and administered an additional questionnaire. Respondents included LMIC pediatric surgeons, HIC pediatric surgeons and HIC pediatric urologists and LMIC urologists and general surgeons. RESULTS Most global surgical visits were short one-time visit, and respondents citing complex pediatric urologic patients as most neglected in LMICs with the main challenge reported as a lack of specialist surgeons, poor communication between groups and poor infrastructure. Local specialist training was universally recommended as the most effective way to address unmet needs, although the form of training was not clear. DISCUSSION Most published work has looked at global general surgery or pediatric general surgery [1][2][3][6][8][11][13] but little on pediatric urology. Most of the information provided was blog posts of social engagements but rarely did these websites provide information on the surgical experience, challenges and solutions gleaned overtime[41][43][44][45][56] It is recognised by pediatric urologists, general urologists and pediatric surgeons that complex urologic anomalies are the most neglected among children's surgical conditions with a higher disability weight attributed to urologic conditions compared to anorectal conditions. [6][8][14][27][31][36][46], yet there's little expertise on ground and many challenges to its advancement. This study was limited by the number of questions we could explore due to the need to make questions fewer and more concise. CONCLUSIONS Pediatric urological conditions remain among the most neglected in global surgery. Current missions face significant challenges that may result in suboptimal outcomes. A comprehensive effort to establish guidelines for these missions is imperative.
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Affiliation(s)
- Phyllis Kisa
- Division of Pediatric Urology, Department of Urologic Sciences, University of British Columbia, Canada; Department of Surgery, Makerere University, Kampala, Uganda.
| | - Kymora Scotland
- Department of Urology, University of California Los Angeles, USA
| | - Kourosh Afshar
- Division of Pediatric Urology, Department of Urologic Sciences, University of British Columbia, Canada
| | - Andrew E MacNeily
- Division of Pediatric Urology, Department of Urologic Sciences, University of British Columbia, Canada
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11
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Geospatial Mapping of International Neurosurgical Partnerships and Evaluation of Extent of Training and Engagement. World Neurosurg 2020; 144:e898-e907. [PMID: 32992055 DOI: 10.1016/j.wneu.2020.09.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the presence, extent, and temporality of transnational neurosurgical partnerships, to understand and inform measures to address neurosurgical deficiencies in low- and middle-income countries (LMICs). METHODS A Web search was conducted to identify actors from high-income countries (HICs) participating in neurosurgical delivery and/or capacity-building with LMICs from 2010 to 2018. Descriptive data on current neurosurgical partnerships were collected from published case reports, literature reviews, reports from academic institutions, and information on stakeholder Web pages. The level of training and engagement of each partnership was separately graded based on prespecified criteria, in which grade 3 represented partnerships that have most extensive training and engagement, and grade 1, the least extent. Data were analyzed using descriptive statistics and geospatially depicted on ArcMap GIS software. RESULTS A total of 123 unique HIC-LMIC partnerships were described. Of these partnerships, 85 (69%) are derived from HICs in North America, followed by Europe, with 23 (19%). The most common LMIC partners were from Africa (n = 56, 45%) and Latin America (n = 32, 26%). In addition, most partnerships provided services in pediatric neurosurgery (88%). The most frequent engagement classifications were grade 2 (35%) or 1 (36%). Similarly, for training, the most common classifications were grade 1 (40%) or 2 (30%). CONCLUSIONS A robust network of HIC-LMIC partnerships exists with varying degrees of engagement and training activities. Several regions are particularly suitable for growth and development. Systematic consolidation and indexing of transnational neurosurgical partnerships aim to enhance resource allocation and present opportunities for future partnership.
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12
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Wasserman I, Peters AW, Roa L, Amanullah F, Samad L. Breaking Specialty Silos: Improving Global Child Health Through Essential Surgical Care. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:183-189. [PMID: 32606090 PMCID: PMC7326524 DOI: 10.9745/ghsp-d-20-00009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/19/2020] [Indexed: 01/17/2023]
Abstract
Children’s health care providers and children’s surgery providers can partner to improve children’s health by developing the surgical workforce, focusing on “best buy” surgeries, integrating children’s surgery into national plans, streamlining data collection and research, and leveraging financing.
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Affiliation(s)
- Isaac Wasserman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Alexander W Peters
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Canada
| | | | - Lubna Samad
- Center for Essential Surgical and Acute Care, Indus Health Network, Karachi, Pakistan
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13
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Hamad D, Yousef Y, Caminsky NG, Guadagno E, Tran VA, Laberge JM, Emil S, Poenaru D. Defining the critical pediatric surgical workforce density for improving surgical outcomes: a global study. J Pediatr Surg 2020; 55:493-512. [PMID: 31839371 DOI: 10.1016/j.jpedsurg.2019.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/02/2019] [Accepted: 11/05/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Low- and middle-income countries (LMICs) have only 19% of the global surgical workforce yet see 80% of worldwide deaths from noncommunicable diseases. We aimed to interrogate the correlation between pediatric surgical workforce density (PSWD) and survival from pediatric surgical conditions worldwide. METHODS A systematic review of online databases identified outcome studies for key pediatric surgical conditions (gastroschisis, esophageal atresia, intestinal atresia, and typhoid perforation) as well as PSWD data across low-income (LICs), middle-income (MICs), and high-income countries (HICs). PSWD was expressed as the number of PSs/million children under 15 years of age and we correlated this to surgical outcomes for our case series. RESULTS PSWD ranged between zero (Burundi, The Gambia, and Mauritania) and 125.2 (Poland) across 86 countries. Outcomes for at least one condition were obtained in 61 countries: 50 outcomes in HICs, 52 in MICs and 8 in LICs. The mean survival in our case series was 42.3%, 69.4% and 91.6% for LICs, MICs, and HICs, respectively. A PSWD ≥4 PSs/million children under 15 years of age significantly correlated to odds of survival ≥80% (OR 16.8, p < 0.0001, 95% CI 5.66-49.88). Specifically in the studied LICs and MICs, increasing the PSWD to 4 would require training 1427 additional surgeons. CONCLUSION Using a novel approach, we have established a benchmark for the scale-up of pediatric surgical workforce, which may support broader efforts to reduce childhood deaths from congenital disease. LEVELS OF EVIDENCE 2c - Outcomes Research.
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Affiliation(s)
- Doulia Hamad
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Natasha G Caminsky
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elena Guadagno
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Viet Anh Tran
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Seyi-Olajide JO, Ameh EA. Investing in Pediatric Surgical Research to Advance Universal Health Coverage for Children in Nigeria. Niger J Surg 2020; 26:1-8. [PMID: 32165829 PMCID: PMC7041358 DOI: 10.4103/njs.njs_43_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 10/22/2019] [Indexed: 11/21/2022] Open
Abstract
About 1.7 billion children and adolescents most of whom are in low- and middle-income countries lack access to safe and affordable surgical and anesthesia care when needed. 43% of Nigeria's population of 199 million are below the age of 15 years. In 2015, Nigeria had a pediatric surgeon workforce deficit of 693 for children <15 years. While threats and constraints to achieving universal health coverage in Nigeria have been highlighted, the role of research is often not included. Over the years, there has been a slow but progressive increase in pediatric surgical workforce and research output, both locally and with international collaborations, and in trainee involvement in research as lead authors. There has unfortunately been a challenge with translation of research findings, outcomes, and recommendations into actions. Despite the various challenges mitigating against pediatric surgery research, efforts must be committed to developing and implementing innovative approaches to address the problems and challenges, as well as implementing quality improvement programs and deploying technology to advance children's care. It is hoped that inclusion of children's surgery in the National Surgical, Obstetrics, Anaesthesia, and Nursing Plan would strengthen pediatric surgical research in Nigeria.
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Affiliation(s)
- Justina O Seyi-Olajide
- Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Emmanuel A Ameh
- Department of Surgery, Division of Paediatric Surgery, National Hospital, Abuja, Nigeria
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Abstract
Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.
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16
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Kakembo N, Grabski DF, Fitzgerald TN, Muzira A, Cheung M, Kisa P, Sekabira J, Ozgediz D. Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda. Surg Infect (Larchmt) 2019; 21:130-135. [PMID: 31560249 DOI: 10.1089/sur.2019.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. Methods: A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Results: Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. Conclusion: There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - John Sekabira
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Doruk Ozgediz
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
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Yousef Y, Lee A, Ayele F, Poenaru D. Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries. J Pediatr Surg 2019; 54:845-853. [PMID: 30017069 DOI: 10.1016/j.jpedsurg.2018.06.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/24/2018] [Accepted: 06/13/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs). METHODS We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes. RESULTS The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases). CONCLUSION These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need. TYPE OF STUDY Retrospective study and review article LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Decarie Blvd, Room B04.2028, Montreal, Quebec, H4A3J1, Canada.
| | - Angela Lee
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Decarie Blvd, Room B04.2028, Montreal, Quebec, H4A3J1, Canada
| | - Frehun Ayele
- MyungSung Christian Medical Center, MyungSung Medical College, PO, Box 15478, Addis Ababa, Ethiopia
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Decarie Blvd, Room B04.2028, Montreal, Quebec, H4A3J1, Canada
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18
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Yousef Y, St-Louis E, Baird R, Smith ER, Guadagno E, St-Vil D, Poenaru D. A systematic review of capacity assessment tools in pediatric surgery: Global Assessment in Pediatric Surgery (GAPS) Phase I. J Pediatr Surg 2019; 54:831-837. [PMID: 30638893 DOI: 10.1016/j.jpedsurg.2018.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 10/24/2018] [Accepted: 11/18/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery highlighted global surgical need but offered little insight into the specific surgical challenges of children in low-resource settings. Efforts to strengthen the quality of global pediatric surgical care have resulted in a proliferation of partnerships between low-and middle-income countries (LMICs) and high-income countries (HICs). Standardized tools able to reliably measure gaps in delivery and quality of care are important aids for these partnerships. We undertook a systematic review (SR) of capacity assessment tools (CATs) focused on needs assessment in pediatric surgery. METHODS A comprehensive search strategy of multiple electronic databases was conducted per PRISMA guidelines without linguistic or temporal restrictions. CATs were selected according to pre-defined inclusion criteria. Articles were assessed by two independent reviewers. Methodological quality of studies was appraised using the COSMIN checklist with 4-point scale. RESULTS The search strategy generated 16,641 original publications, of which three CATs were deemed eligible. Eligible tools were either excessively detailed or oversimplified. None used weighted scores to identify finer granularity between institutions. No CATs comprehensively included measures of resources, outcomes, accessibility/impact and training. DISCUSSION The results of this study identify the need for a CAT capable of objectively measuring key aspects of surgical capacity and performance in a weighted tool designed for pediatric surgical centers in LMICs. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yasmine Yousef
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital; Centre Hospitalier de l'Université de Montréal, Hôpital Sainte-Justine, Département de chirurgie générale pédiatrique.
| | - Etienne St-Louis
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | - Robert Baird
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | | | - Elena Guadagno
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
| | - Dickens St-Vil
- Centre Hospitalier de l'Université de Montréal, Hôpital Sainte-Justine, Département de chirurgie générale pédiatrique
| | - Dan Poenaru
- McGill University Health Center, Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital
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Concepcion T, Mohamed M, Dahir S, Adan Ismail E, Poenaru D, Rice HE, Smith ER. Prevalence of Pediatric Surgical Conditions Across Somaliland. JAMA Netw Open 2019; 2:e186857. [PMID: 30646203 PMCID: PMC6484554 DOI: 10.1001/jamanetworkopen.2018.6857] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Tessa Concepcion
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Shugri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Dan Poenaru
- Department of Pediatric Surgery, McGill University Health Centre, Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Henry E. Rice
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Emily R. Smith
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas
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20
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Rural and urban differences in treatment status among children with surgical conditions in Uganda. PLoS One 2018; 13:e0205132. [PMID: 30383756 PMCID: PMC6211669 DOI: 10.1371/journal.pone.0205132] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/19/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In low and middle-income countries, approximately 85% of children have a surgically treatable condition before the age of 15. Within these countries, the burden of pediatric surgical conditions falls heaviest on those in rural areas. The objective of the current study was to evaluate the relationship between rurality, surgical condition and treatment status among a cohort of Ugandan children. METHODS We identified 2176 children from 2315 households throughout Uganda using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey. Children were randomly selected and were included in the study if they were 18 years of age or younger and had a surgical condition. Location of residence, surgical condition, and treatment status was compared among children. RESULTS Of the 305 children identified with surgical conditions, 81.9% lived in rural areas. The most prevalent causes of surgical conditions reported among rural and urban children were masses (24.0% and 25.5%, respectively), followed by wounds due to injury (19.6% and 16.4%, respectively). Among children with untreated surgical conditions, 79.1% reside in rural areas while 20.9% reside in urban areas. Among children with untreated surgical conditions, the leading reason for not seeking surgical care among children living in both rural and urban areas was a lack of money (40.6% and 31.4%, respectively), and the leading reason for not receiving care in both rural and urban settings was a lack of money (48.0% and 42.8%, respectively). CONCLUSIONS Our data suggest that over half of the children with a surgical condition surveyed are not receiving surgical care and a large majority of children with surgical needs were living in rural areas. Future interventions aimed at increasing surgical access in rural areas in low-income countries are needed.
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22
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Butler M, Drum E, Evans FM, Fitzgerald T, Fraser J, Holterman AX, Jen H, Kynes M, Kreiss J, McClain CD, Newton M, Nwomeh B, O'Neill J, Ozgediz D, Politis G, Rice H, Rothstein D, Sanchez J, Singleton M, Yudkowitz FS. Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group. Paediatr Anaesth 2018; 28:392-410. [PMID: 29870136 DOI: 10.1111/pan.13378] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2018] [Indexed: 12/19/2022]
Abstract
Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries are increasingly engaged in resource-limited areas, with short-term missions as the most common form of involvement. However, consensus recommendations currently do not exist for short-term missions in pediatric general surgery and associated perioperative care. The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for short-term missions based on extensive experience with short-term missions. Three distinct, but related areas were identified: (i) Broad goals of surgical partnerships between high-income countries and low- and middle-income countries. A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN) was endorsed by all groups; (ii) Guidelines for the conduct of short-term missions were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; and (iii) travel and safety considerations critical to short-term mission success were enumerated. A diverse group of stakeholders developed these guidelines for short-term missions in low- and middle-income countries. These guidelines may be a useful tool to ensure safe, responsible, and ethical short-term missions given increasing engagement of high-income country providers in this work.
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Affiliation(s)
- Marilyn Butler
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth Drum
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Faye M Evans
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jason Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ai-Xuan Holterman
- Division of Pediatric Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Howard Jen
- Division of Pediatric Surgery, University of California, Los Angeles, CA, USA
| | - Matthew Kynes
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University, Nashville, TN, USA
| | - Jenny Kreiss
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Craig D McClain
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Newton
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University, Nashville, TN, USA.,Department of Anesthesiology and Pediatrics, Kijabe Hospital, Kijabe, Kenya
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - James O'Neill
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
| | - Doruk Ozgediz
- Section of Pediatric Surgery, Yale University, New Haven, CT, USA
| | - George Politis
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Henry Rice
- Division of Pediatric Surgery, Duke University, Durham, NC, USA
| | - David Rothstein
- Division of Pediatric Surgery, Children's Hospital of Buffalo, Buffalo, NY, USA
| | - Julie Sanchez
- Division of Pediatric Surgery, University of Texas at Austin, Austin, TX, USA
| | - Mark Singleton
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Pal Alto, CA, USA.,Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
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23
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Krois W, Dingemans AJM, Hernández PX, Metzelder ML, Craniotis Rios J, Reck-Burneo CA. Sociodemographics and the impact of a colostomy to indigent families and children with colorectal disorders in Honduras. J Pediatr Surg 2018; 53:841-846. [PMID: 28528713 DOI: 10.1016/j.jpedsurg.2017.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION To describe the social impact of a colostomy on indigent families and affected children with anorectal malformations (ARM) or Hirschsprung's disease (HD) in San Pedro Sula, Honduras, we specifically targeted very low-income households that attended an international medical brigade for ARM and HD in 2016. METHODS The impact of a colostomy on the families and children's daily life was analyzed by personal interviews with a questionnaire. RESULTS Twenty families with children were included in the study. Children's age ranged from 5 months to 27years (median 2.31). Annual income was reported to be less than $500 USD in 42.8%. Impairment of daily family life by the colostomy was reported in 85%. Parents of preschool children younger than 7 years are more affected than parents of older children, whereas children older than 7 years reported on more social problems. Moreover, 50% of the school-aged children did not attend school owing to issues directly related to their colostomy. DISCUSSION Colostomies for children in the low middle-income country Honduras have significant social and economic implications for low-income families. In ARM and HD, medical brigades can offer help for definitive surgical repair to overcome and shorten the period of a colostomy presence to improve physical and psychosocial impairment, especially when performed before the children reach the school age. TYPE OF STUDY Cost Effectiveness Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- W Krois
- Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria.
| | | | | | - M L Metzelder
- Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
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Butler M, Drum E, Evans FM, Fitzgerald T, Fraser J, Holterman AX, Jen H, Kynes JM, Kreiss J, McClain CD, Newton M, Nwomeh B, O'Neill J, Ozgediz D, Politis G, Rice H, Rothstein D, Sanchez J, Singleton M, Yudkowitz FS. Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group. J Pediatr Surg 2018; 53:828-836. [PMID: 29223665 DOI: 10.1016/j.jpedsurg.2017.11.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/05/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Marilyn Butler
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University
| | - Elizabeth Drum
- Department of Anesthesiology & Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania
| | - Faye M Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School
| | | | - Jason Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City
| | - Ai-Xuan Holterman
- Division of Pediatric Surgery, University of Illinois College of Medicine at Peoria
| | - Howard Jen
- Division of Pediatric Surgery, University of California, Los Angeles
| | - J Matthew Kynes
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University
| | - Jenny Kreiss
- Division of Pediatric Surgery, Seattle Children's Hospital
| | - Craig D McClain
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School
| | - Mark Newton
- Department of Anesthesia, Vanderbilt Children's Hospital, Vanderbilt University
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - James O'Neill
- Department of Pediatric Surgery, Vanderbilt University
| | | | - George Politis
- Department of Anesthesiology, University of Virginia Health System
| | - Henry Rice
- Division of Pediatric Surgery, Duke University
| | - David Rothstein
- Division of Pediatric Surgery, Children's Hospital of Buffalo
| | - Julie Sanchez
- Division of Pediatric Surgery, University of Texas at Austin
| | - Mark Singleton
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Department of Anesthesia and Perioperative Care, University of California San Francisco
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25
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Burgos CM, Bolkan HA, Bash-Taqi D, Hagander L, von Schreeb J. The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap. World J Surg 2018; 42:652-665. [PMID: 28932917 PMCID: PMC5801385 DOI: 10.1007/s00268-017-4244-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. AIM To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. METHODS We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. RESULTS In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%. CONCLUSIONS The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.
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Affiliation(s)
| | - Håkon Angell Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Lars Hagander
- Surgery and Public Health, Pediatric Surgery, Department of Clinical Sciences in Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan von Schreeb
- Global Health-Health System and Policy Department of Public Health Sciences, Centre for Research on Health Care in Disasters, Stockholm, Sweden
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26
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Farmer DL. Audacious Goals - 2.0 The Global Initiative for Children's Surgery. J Pediatr Surg 2017; 53:S0022-3468(17)30629-2. [PMID: 29173774 DOI: 10.1016/j.jpedsurg.2017.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/05/2017] [Indexed: 12/17/2022]
Abstract
This is the Presidential Address given at the 48th Annual Meeting of the American Pediatric Surgical Association (APSA) held in Hollywood, Florida, from May 4-7, 2017.
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Affiliation(s)
- Diana Lee Farmer
- Department of Surgery, University of California, Davis School of Medicine, UC Davis Children's Hospital.
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Conway DJ, Coughlin R, Caldwell A, Shearer D. The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery. Front Public Health 2017; 5:146. [PMID: 28713803 PMCID: PMC5491941 DOI: 10.3389/fpubh.2017.00146] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/09/2017] [Indexed: 01/15/2023] Open
Abstract
In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT's partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners.
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Affiliation(s)
- Devin James Conway
- University of California San Francisco, San Francisco, CA, United States
| | - Richard Coughlin
- University of California San Francisco, San Francisco, CA, United States
| | - Amber Caldwell
- University of California San Francisco, San Francisco, CA, United States
| | - David Shearer
- University of California San Francisco, San Francisco, CA, United States
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Butler EK, Tran TM, Nagarajan N, Canner J, Fuller AT, Kushner A, Haglund MM, Smith ER. Epidemiology of pediatric surgical needs in low-income countries. PLoS One 2017; 12:e0170968. [PMID: 28257418 PMCID: PMC5336197 DOI: 10.1371/journal.pone.0170968] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/13/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE According to recent estimates, at least 11% of the total global burden of disease is attributable to surgically-treatable diseases. In children, the burden is even more striking with up to 85% of children in low-income and middle-income countries (LMIC) having a surgically-treatable condition by age 15. Using population data from four countries, we estimated pediatric surgical needs amongst children residing in LMICs. METHODS A cluster randomized cross-sectional countrywide household survey (Surgeons OverSeas Assessment of Surgical Need) was done in four countries (Rwanda, Sierra Leone, Nepal and Uganda) and included demographics, a verbal head to toe examination, and questions on access to care. Global estimates regarding surgical need among children were derived from combined data, accounting for country-level clustering. RESULTS A total of 13,806 participants were surveyed and 6,361 (46.1%) were children (0-18 years of age) with median age of 8 (Interquartile range [IQR]: 4-13) years. Overall, 19% (1,181/6,361) of children had a surgical need and 62% (738/1,181) of these children had at least one unmet need. Based on these estimates, the number of children living with a surgical need in these four LMICs is estimated at 3.7 million (95% CI: 3.4, 4.0 million). The highest percentage of unmet surgical conditions included head, face, and neck conditions, followed by conditions in the extremities. Over a third of the untreated conditions were masses while the overwhelming majority of treated conditions in all countries were wounds or burns. CONCLUSION Surgery has been elevated as an "indivisible, indispensable part of health care" in LMICs and the newly formed 2015 Sustainable Development Goals are noted as unachievable without the provision of surgical care. Given the large burden of pediatric surgical conditions in LMICs, scale-up of services for children is an essential component to improve pediatric health in LMICs.
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Affiliation(s)
- Elissa K Butler
- Department of Surgery, University of Washington, Seattle, WA, United States of America
| | - Tu M Tran
- Duke University Global Health Institute, Durham, NC, United States of America
| | - Neeraja Nagarajan
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joseph Canner
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Anthony T Fuller
- Duke University Division of Global Neurosurgery and Neuroscience, Durham, NC, United States of America.,Duke University School of Medicine, Durham, NC, United States of America
| | - Adam Kushner
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Michael M Haglund
- Duke University Global Health Institute, Durham, NC, United States of America.,Duke University Division of Global Neurosurgery and Neuroscience, Durham, NC, United States of America.,Duke University School of Medicine, Durham, NC, United States of America.,Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States of America
| | - Emily R Smith
- Duke University Global Health Institute, Durham, NC, United States of America.,Duke University Division of Global Neurosurgery and Neuroscience, Durham, NC, United States of America
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Kligerman MP, Alexandre A, Jean-Gilles P, Walmer D, Cheney ML, Messner AH. Otorhinolaryngology/Head and Neck Surgery in a low income country: The Haitian experience. Int J Pediatr Otorhinolaryngol 2017; 93:128-132. [PMID: 28109483 DOI: 10.1016/j.ijporl.2016.12.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 12/28/2016] [Accepted: 12/28/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Little is known regarding the diagnosis and management of pediatric surgical conditions of the head and neck in low-income countries. Haiti, the western hemisphere's poorest country, recently developed its first Otorhinolaryngology (ORL) department at the Hopital de L'Universite d'Etat d'Haiti (HUEH). This manuscript assesses the caseload at HUEH with a special emphasis on pediatric cases, with the aim of characterizing ORL related conditions and their treatments in low-income countries. METHODS We conducted a retrospective chart review of surgical case logs at HUEH for the calendar year of 2014 and recorded patient age, diagnosis, and surgical intervention for all ORL surgeries. RESULTS A total of 229 ORL surgeries were performed at HUEH during this time. The average age of the patient was 21.8 years and 54.2% of patients were 18 years or younger. The five most common diagnoses were tonsillar hypertrophy (23.6%), ingested foreign body (18%), mandibular fracture (9.2%), unspecified head or neck mass (6%), and thyroid goiter (4.8%). The five most common surgeries performed were tonsillectomy (23.6%), foreign body retrieval (17.9%), open reduction of mandibular fracture with direct skeletal fixation (6.9%), thyroidectomy (7.9%), and excision of unspecified mass. Trauma accounted for 33.6% of all ORL surgeries. CONCLUSIONS Diseases related to the head and neck constitute a common yet underserved surgical problem. Strengthening ORL surgical capacity in Haiti should focus on improving capacity for the most common conditions including tonsillar disease, ingested foreign bodies, and facial trauma, as well as improving capacity for rarely performed surgeries, such as ear surgery, nose and sinus surgery, and cancer resections.
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Affiliation(s)
- Maxwell P Kligerman
- Stanford University School of Medicine, Stanford, CA, USA; Family Health Ministries, 501-C3, Durham, NC, USA.
| | - Anahuma Alexandre
- Department of Otorhinolaryngology, Hopital de L'Universite d'Etat d'Haiti, Port-au-Prince, Haiti
| | - Patrick Jean-Gilles
- Department of Otorhinolaryngology, Hopital de L'Universite d'Etat d'Haiti, Port-au-Prince, Haiti
| | - David Walmer
- Duke Global Health Institute, Duke University, USA; Family Health Ministries, 501-C3, Durham, NC, USA
| | - Mack L Cheney
- Massachusetts Eye and Ear Infirmary, Harvard School of Medicine, USA
| | - Anna H Messner
- Department of Otolaryngology/Head & Neck Surgery, Stanford University, Stanford, CA, USA
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