Establishing a sustainable healthcare environment in low- and middle-income countries

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries

BACKGROUND

Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings.

METHODS

We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon.

RESULTS

Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up.

CONCLUSIONS

Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

South African Healthcare Professionals' Knowledge, Attitudes, and Practices Regarding Environmental Sustainability in Healthcare: A Mixed-Methods Study

Climate change, biodiversity loss and large-scale environmental degradation are widely recognized as the biggest health threats of the 21st century, with the African continent already amongst the most severely affected and vulnerable to their further progression. The healthcare system's contribution to climate change and environmental degradation requires healthcare professionals to address environmental issues urgently. However, the foundation for context-relevant interventions across research, practice, and education is not readily available. Therefore, we conducted a convergent mixed-methods study to investigate South African healthcare professionals' knowledge, attitudes, practices, and barriers to environmental sustainability. Healthcare professionals participated in a cross-sectional questionnaire (n = 100) and in-depth semi-structured focus group discussions (n = 18). Data were analyzed using descriptive statistics and thematic analysis, respectively, and integrated to provide holistic findings. Our results confirm overwhelmingly positive attitudes and a high degree of interest in education, implementation, and taking on more corresponding responsibility, but a lack of substantial knowledge of the subject matter, and only tentative implementation of practices. Identified barriers include a lack of knowledge, resources, and policies. Further research, education, and policy development on overcoming these barriers is required. This will facilitate harnessing the extant enthusiasm and advance environmental sustainability in South Africa's healthcare practice.

Disseminating surgical experience for sustainable benefits - the Urolink experience

The dissemination of urological knowledge, and consequent surgical expertise, is entirely dependent on the availability of individuals to provide education and the mechanism by which that knowledge is spread. In low, or low-middle, income countries the numbers of specialist surgeons, especially urologists, is extremely limited and the time they have to train aspiring urologists is, therefore, restricted as a consequence of the demand for clinical help. Urologists from high-income countries, being more prevalent, can assist with the education, but are limited by the needs of their own careers and the time they have available to educate in a resource poor setting. Bringing surgeons from a low to a high income environment for training is one option to overcome this trainer/trainee imbalance, but is relatively expensive, bureaucratic, and has inherent risks of the individual being lost from their domestic workforce. Short-term medical trips to educate larger numbers of individuals in their home setting is one of a number of different options that has been used to bridge this gap. It has, however, been suggested that such a model is not the most efficient way of perpetuating knowledge and skills in a low-income environment. Urolink has found, however, that when short term trips are used to support a longitudinal commitment to a centre they can be remarkable effective. By helping the expansion of personnel to a critical mass in designated regional hubs, linked to credible local or regional academic institutions, it has been possible to develop sustainable centres that can disseminate training across a wide geographical area. Such a co-operative approach has been used between Urolink and the Kilimanjaro Christian Medical Centre in Moshi, Tanzania, a model that has initiated the evolution of other regional training hubs across east Africa over the last three decades.

The benefits of virtual learning webinars to both low and high-income countries

The 2019 Covid pandemic has brought about many changes in the relationships between high income countries (HICs) and partner organisations in low or low-middle income countries (LMICs), such as predominate in sub-Saharan Africa. Medicine, surgery and in particular urology is no exception to the changes that Covid-19 has demanded. Urolink represents the British Association of Urological Surgeons (BAUS) on the global urology stage and has been deleteriously impacted by the pandemic. Education, one of the pillars of Urolink's founding philosophies, has conventionally been delivered by face-to face (F2F) teaching, training or mentoring by UK urologists at their host's site outside of the United Kingdom (UK). As a consequence of the inability to travel due to the pandemic, BAUS Urolink has evolved a virtual online webinar package evolved by, and delivered between, urologists in Lusaka, Zambia, and various centres in the United Kingdom. The aim was to deliver curricular-based educational topics to trainees in both countries. This programme has generated a number of live webinars, and archived recordings, during the pandemic that has proven accessible, and educationally acceptable, to trainees in the UK and Zambia. This webinar series has also generated relationships between young urologists on different continents, given each a different view of healthcare delivery outside of their country of origin at no appreciable cost, and would appear to be an educational mechanism that is durable for, and applicable to, a wider participation in the post-pandemic world.