The State of Artificial Intelligence in Pediatric Surgery: A Systematic Review

BACKGROUND

Artificial intelligence (AI) has been recently shown to improve clinical workflows and outcomes - yet its potential in pediatric surgery remains largely unexplored. This systematic review details the use of AI in pediatric surgery.

METHODS

Nine medical databases were searched from inception until January 2023, identifying articles focused on AI in pediatric surgery. Two authors reviewed full texts of eligible articles. Studies were included if they were original investigations on the development, validation, or clinical application of AI models for pediatric health conditions primarily managed surgically. Studies were excluded if they were not peer-reviewed, were review articles, editorials, commentaries, or case reports, did not focus on pediatric surgical conditions, or did not employ at least one AI model. Extracted data included study characteristics, clinical specialty, AI method and algorithm type, AI model (algorithm) role and performance metrics, key results, interpretability, validation, and risk of bias using PROBAST and QUADAS-2.

RESULTS

Authors screened 8178 articles and included 112. Half of the studies (50%) reported predictive models (for adverse events [25%], surgical outcomes [16%] and survival [9%]), followed by diagnostic (29%) and decision support models (21%). Neural networks (44%) and ensemble learners (36%) were the most commonly used AI methods across application domains. The main pediatric surgical subspecialties represented across all models were general surgery (31%) and neurosurgery (25%). Forty-four percent of models were interpretable, and 6% were both interpretable and externally validated. Forty percent of models had a high risk of bias, and concerns over applicability were identified in 7%.

CONCLUSIONS

While AI has wide potential clinical applications in pediatric surgery, very few published AI algorithms were externally validated, interpretable, and unbiased. Future research needs to focus on developing AI models which are prospectively validated and ultimately integrated into clinical workflows.

LEVEL OF EVIDENCE

2A.

ChatGPT: What Every Pediatric Surgeon Should Know About Its Potential Uses and Pitfalls

ChatGPT - currently the most popular generative artificial intelligence system - has been revolutionizing the world and healthcare since its release in November 2022. ChatGPT is a conversational chatbot that uses machine learning algorithms to enhance its replies based on user interactions and is a part of a broader effort to develop natural language processing that can assist people in their daily lives by understanding and responding to human language in a useful and engaging way. Thus far, many potential applications within healthcare have been described, despite its relatively recent release. This manuscript offers the pediatric surgical community a primer on this new technology and discusses some initial observations about its potential uses and pitfalls. Moreover, it introduces the perspectives of medical journals and surgical societies regarding the use of this artificial intelligence chatbot. As ChatGPT and other large language models continue to evolve, it is the responsibility of the pediatric surgery community to stay abreast of these changes and play an active role in safely incorporating them into our field for the benefit of our patients. LEVEL OF EVIDENCE: V.

Using Artificial Intelligence to Label Free-Text Operative and Ultrasound Reports for Grading Pediatric Appendicitis

PURPOSE

Data science approaches personalizing pediatric appendicitis management are hampered by small datasets and unstructured electronic medical records (EMR). Artificial intelligence (AI) chatbots based on large language models can structure free-text EMR data. We compare data extraction quality between ChatGPT-4 and human data collectors.

METHODS

To train AI models to grade pediatric appendicitis preoperatively, several data collectors extracted detailed preoperative and operative data from 2100 children operated for acute appendicitis. Collectors were trained for the task based on satisfactory Kappa scores. ChatGPT-4 was prompted to structure free text from 103 random anonymized ultrasound and operative records in the dataset using the set variables and coding options, and to estimate appendicitis severity grade from the operative report. A pediatric surgeon then adjudicated all data, identifying errors in each method.

RESULTS

Within the 44 ultrasound (42.7%) and 32 operative reports (31.1%) discordant in at least one field, 98% of the errors were found in the manual data extraction. The appendicitis grade was erroneously assigned manually in 29 patients (28.2%), and by ChatGPT-4 in 3 (2.9%). Across datasets, the use of the AI chatbot was able to avoid misclassification in 59.2% of the records including both reports and extracted data approximately 40 times faster.

CONCLUSION

AI chatbot significantly outperformed manual data extraction in accuracy for ultrasound and operative reports, and correctly assigned the appendicitis grade. While wider validation is required and data safety concerns must be addressed, these AI tools show significant promise in improving the accuracy and efficiency of research data collection.

LEVELS OF EVIDENCE

Level III.

The Impact of Educational Materials on Parental Anxiety and Productivity: A Clinical Trial in Pediatric Appendicitis

OBJECTIVES

There is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness.

METHODS

A quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t-tests, Mann-Whitney, chi-square, or Fischer's exact test as appropriate.

RESULTS

Phases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss.

CONCLUSIONS

Educational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes.

TYPE OF STUDY

Non-Randomized Clinical Trial.

LEVEL OF EVIDENCE

II.

Adaptation, Translation, and Validation of a Patient-Reported Experience Measure for Children and Young People for the Canadian Context

BACKGROUND

Patient-reported experience measures (PREMs) evaluate children's and young people's (CYP) perceptions of care. An important PREM developed with and for children was created in London, UK. Given the absence of similar North American instruments, we aimed to adapt, translate, and linguistically validate this instrument for use in a Canadian pediatric outpatient setting.

METHODS

A qualitative design was used, involving CYP and their parents/caregivers. Phase 1 entailed the English survey adaptation using think-aloud testing, revision, and cognitive testing. Phase 2 involved translation into French, revision and back-translation, and cognitive testing. Phase 3 encompassed a cross-validation of the English and French versions of the adapted instrument.

RESULTS

Fifty-five children in 3 age groups (8-11y, 12-13y, 14-16y) participated in creating the Canadian PREM. In Phases 1 and 2, 41 children participated in reviewing and updating specific questions in the instrument, resulting in adjustments and revisions based on their feedback. In Phase 3, 14 bilingual children linguistically validated the PREM instrument.

CONCLUSIONS

This study reports the development of the first Canadian PREM specifically tailored to children. By incorporating the perspectives and preferences of CYP in clinical practice, this approach has the potential to amplify the delivery of patient-centered care for this vulnerable population and ensure that the needs and voices of CYP are acknowledged.

LEVEL OF EVIDENCE

V, Therapeutic.

Improving Pediatric Trauma Education by Teaching Non-technical Skills: A Randomized Controlled Trial

BACKGROUND

Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation.

METHODS

A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t-tests, Mann-Whitney, Wilcoxon signed-rank Kruskal-Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05.

RESULTS

The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps.

CONCLUSION

Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education.

LEVEL OF EVIDENCE

I.

Patient-Centered Surgical Care for Children in Low and Lower-Middle Income Countries (LMICs) - A Systematic Scoping Review of the Literature

PURPOSE

Studies exploring patient-centered care (PCC) in pediatric surgery have been disproportionately concentrated in high-income countries. This review aims to characterize the adoption of key PCC domains in low and lower-middle income countries (LMICs).

METHODS

Seven databases were searched from inception until January 2023 to retrieve relevant articles in pediatric surgery in LMICs. We focused on six key PCC domains: patient-reported outcomes (PROs), patient-reported experiences (PREs), shared decision-making (SDM), patient/parent education, patient/parent satisfaction, and informed consent.

RESULTS

Of 8050 studies screened, 230 underwent full-text review, and 48 were finally included. Most were single-center (87.5%), cross-sectional studies (41.7%) from the South-East Asian (35.4%) and Eastern Mediterranean regions (33.3%). Studies most frequently focused on postoperative care (45.8%) in pediatric general surgery (18.8%), and included 1-3 PCC domains. PREs (n = 30), PROs (n = 16) and patient/parent satisfaction (n = 16) were most common. Informed consent (n = 2) and SDM (n = 1) were least studied. Only 13 studies directly elicited children's perspectives. Despite all studies originating in LMICs, 25% of first and 17.8% of senior authors lacked LMIC affiliations.

CONCLUSION

The adoption of PCC in LMICs appears limited, focusing predominantly on PROs and PREs. Other domains such as informed consent and SDM are rarely addressed, and the voice of children and young people is rarely heard in their care. Opportunities to enhance PCC in LMICs abound, with the potential to improve the surgical care of children in resource-limited settings.

LEVEL OF EVIDENCE

III.

Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo

INTRODUCTION

Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC.

METHODS

Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people.

RESULTS

Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant.

CONCLUSIONS

The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

Defining Feasibility as a Criterion for Essential Surgery: A Qualitative Study with Global Children's Surgery Experts

BACKGROUND

The Disease Control Priorities (DCP-3) group defines surgery as essential if it addresses a significant burden, is cost-effective, and is feasible-yet the feasibility component remains largely unexplored. The aim of this study was to develop a precise definition of feasibility for essential surgical procedures for children.

METHODS

Four online focus group discussions (FGDs) were organized among 19 global children's surgery providers with experience of working in low- and lower-middle-income countries (LMICs), representing 10 countries. FGDs were transcribed verbatim, and qualitative data analysis was performed. Codes, categories, themes, and subthemes were identified.

RESULTS

Six determinants of feasibility were identified, including: adequate human resources; adequate material resources; procedure and disease complexity; team commitment and understanding of their setting; timely access to care; and the ability to monitor and achieve good outcomes. Factors unique to feasibility of children's surgery included children's right to health and their reliance on adults for accessing safe and timely care; the need for specialist workforce; and children's unique perioperative care needs. FGD participants reported a greater need for task-sharing and shifting, creativity, and adaptability in resource-limited settings. Resource availability was seen to have a direct impact on decision-making and prioritization, e.g., saving a life versus achieving the best outcome.

CONCLUSIONS

The identification of a precise definition of feasibility serves as a pivotal step in identifying a list of essential surgical procedures for children, which would serve as indicators of institutional surgical capacity for this age group.

The evidence mismatch in pediatric surgical practice

PURPOSE

Outpatient pediatric surgical practice often involves conditions of limited morbidity but significant parental concern. We explore existing evidence-based management recommendations and the mismatch with practice patterns for four common outpatient pediatric surgical conditions.

METHODS

Using the Cochrane Rapid Review Group recommendations and librarian oversight, we conducted a rapid review of four outpatient surgical conditions: dermoid cysts, epigastric hernias, hydroceles, and umbilical hernias. We extracted patient demographics, intervention details, outcome measures and evaluated justifications presented for chosen management options. A metric of evidence volume (patient/publication ratio) was generated and compared between diagnoses.

RESULTS

Out of 831 articles published since 1990, we identified 49 cohort studies (10-dermoid cyst, 6-epigastric hernia, 25-hydrocele, and 8-umbilical hernia). The 49 publications included 34,172 patients treated across 18 countries. The evidence volume for each outpatient condition demonstrates < 1 cohort/condition/year. The evidence mismatch rate varied between 33 and 75%; many existing recommendations are not evidence-based, sometimes conflicting and frequently misrepresentative of clinical practice.

CONCLUSIONS

Published literature concerning common outpatient pediatric surgical conditions is sparse and demonstrates wide variations in practice. All individual practice choices were justified using either risk of complications or patient preference. Most early intervention practices were based on weak or outdated studies and "common wisdom" rather than genuine evidence.

LEVEL OF EVIDENCE

III.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo

INTRODUCTION

In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access.

METHODS

A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed.

RESULTS

Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care.

CONCLUSIONS

Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Screening methods for congenital anomalies in low and lower-middle income countries: A systematic review

INTRODUCTION

Surgically correctable congenital anomalies are responsible for a significant burden of morbidity and mortality in children from low-and lower-middle-income countries (LMICs). Early identification through fetal and neonatal screening is critical to reducing death and disability. This study aims to identify feasible screening methods for surgically correctable congenital anomalies in LMICs.

METHODS

A systematic search looking at screening for congenital anomalies in LMIC was conducted in seven databases from 2000 until May 25, 2020, with no language restriction. All articles discussing screening methods for surgically correctable congenital anomalies in LMICs were included. Articles were screened by two independent contributors using Rayyan software, with a third contributor resolving conflicts. Feasibility of the screening method and its risk of bias were assessed using the MINORS scale.

RESULTS

Of 3473 articles, 24 were included in the full-text review. Nine screening methods (three prenatal and six postnatal) were identified - the most frequently utilized being physician clinical examination (45.8%), pulse oximetry (33.3%) and fetal ultrasound (20.8%). The use of a birth defect picture toolkit was the most feasible screening method. The risk of bias scale yielded an average of 11.9 points, which corresponds to a moderate level of bias.

CONCLUSION

Despite clear benefits, prenatal and neonatal screening methods are infrequently used in LMICs to identify surgically correctable congenital anomalies in neonates, likely due to financial, material, and human resource constraints. Further research into the development of low-cost feasible methods is needed within these settings.

PROSPERO REGISTRATION NUMBER

CRD42020192051.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans: a policy content analysis

OBJECTIVE

While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies.

DESIGN

We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia.

RESULTS

Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed 'human resources and training' and 'infrastructure', four addressed 'service delivery', three addressed 'governance and financing', two included 'research, evaluation and quality improvement', and one NSOAP addressed 'equipment and supplies' and 'advocacy and awareness'.

CONCLUSIONS

Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

"Your child needs surgery": A survey-based evaluation of simulated expert consent conversations by key stakeholders

BACKGROUND

Consent conversations in pediatric surgery are essential components of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, and others in the healthcare system. The aim of this study is to explore expert consenting practice from the key stakeholders' perspective.

METHODS

Four senior attending pediatric surgeons obtained consent from a standardized mother of a child requiring surgery in two scenarios: a low-risk elective surgery (inguinal hernia repair - Video 1), and a high-risk emergency surgery (intestinal atresia - Video 2). All sessions were recorded. Families of children who had undergone minor or major surgery, families without medical or surgical background, and healthcare professionals were invited to view and evaluate the videos using a semi-structured questionnaire.

RESULTS

Out of 251 distributed surveys, 56 complete responses were received. Thirty two participants (57.1%) evaluated video 1 and 24 (42.9%) evaluated. Overall, 22 (69%) respondents to video 1 and 20 (84%) respondents to video 2 were "very satisfied" with the recorded consent conversation. Qualitative responses shared common themes of valuing surgeon empathy, good surgeon communication, patient engagement, and adequate time and information. Suggestions for improvement included additional resources and visual aids, improved patient engagement, and discussion of post-operative expectations.

CONCLUSION

Our data identifies strengths and gaps in the current consent process from the perspective of patient families and providers. Identified areas for improvement in the informed consent process based on multi-stakeholder input will guide the planned development of a consenting educational video resource.

LEVEL OF EVIDENCE

IV.

Patient experience or patient satisfaction? A systematic review of child- and family-reported experience measures in pediatric surgery

PURPOSE

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important health care quality indicators. PREMs measure patients' perception of the care they have received, differing from satisfaction ratings, which measure their expectations. The use of PREMs in pediatric surgery is limited, prompting this systematic review to assess their characteristics and identify areas for improvement.

METHODS

A search was conducted in eight databases from inception until January 12, 2022, to identify PREMs used with pediatric surgical patients, with no language restrictions. We focused on studies of patient experience but also included studies that assessed satisfaction and sampled experience domains. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool.

RESULTS

Following title and abstract screening of 2633 studies, 51 were included for full-text review, of which 22 were subsequently excluded because they measured only patient satisfaction rather than experience, and 14 were excluded for a range of other reasons. Out of the 15 included studies, questionnaires used in 12 studies were proxy-reported by parents and in 3 by both parents and children; none focused only on the child. Most instruments were developed in-house for each specific study, without patients' involvement in the process, and were not validated.

CONCLUSIONS

Although PROMs are increasingly used in pediatric surgery, PREMs are not yet in use, being typically substituted by satisfaction surveys. Significant efforts are needed to develop and implement PREMs in pediatric surgical care, in order to effectively capture children's and families' voices.

LEVEL OF EVIDENCE

IV.

A rapid review for developing a co-design framework for a pediatric surgical communication application

BACKGROUND

The exponential growth in the use of mobile health (mHealth) applications in patient care has highlighted the importance of understanding end-users' needs for successful interventions, achievable through the process of co-design. This review aims to summarize previously published uses of co-design in mHealth applications. It will inform the development of a local mHealth tool in pediatric surgery.

METHODS

The rapid review was conducted following Cochrane Rapid Review guidelines. We searched four databases from inception until August 2021 for collaborative design in mHealth apps. Two reviewers independently screened titles and abstracts using Rayyan, with a third reviewer resolving any conflicts. Studies were excluded if they were non-empirical or in other languages than English.

RESULTS

Out of 984 records screened, 175 were included for full-text screening, and 27 met all eligibility criteria. The purpose of the studies related to care support, communication, self-management or information management. All interventions involved their target audience in the co-design process, and 85% included healthcare professionals for expert opinion. Stakeholder participation was solicited via interviews, surveys, focus groups, design sessions, and prototype evaluation. To initiate the process, 15 studies included needs identification, 8 did background research, and 7 performed literature reviews.

CONCLUSION

Co-design has a positive impact on mHealth development, research processes and outcomes. Its success relies on a clearly identified framework of terminology, activities involved, and evaluation techniques. The findings of this review will be integrated into a novel co-design framework, which will be used to inform the development of a pediatric surgery mHealth application.

LEVEL OF EVIDENCE

This review uses manuscripts that are rated level III-V.

Family risk communication preferences in pediatric surgery: A scoping review

BACKGROUND

Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

METHODS

A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

RESULTS

A total of 6370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

CONCLUSION

Eliciting families' preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

LEVEL OF EVIDENCE

Level IV (Scoping Review).

Exploring trust development in families of children towards surgical and emergency care providers: A scoping review of the literature

BACKGROUND

Trust is central to the therapeutic relationship between patients and their providers, yet little is known about how it is developed in the unique context of children facing surgical emergencies. We sought to identify factors fostering trust development, gaps, and areas for improvement.

METHODS

We searched eight databases from inception to June 2021 to identify studies focusing on trust in pediatric surgical and urgent care settings. PRISMA-ScR protocols were followed, and screening carried out by two independent reviewers. Data collection included study characteristics, outcomes, and results.

RESULTS

Out of 5578 articles screened, 12 fulfilled the inclusion criteria. Four major trust constructs were identified: competence, communication, dependability, and caring. Despite various instruments used, all studies reported a high level of parental trust. Nearly all studies (11/12) noted trust depending on parents' sociodemographic background, with ethnicity (3/12) and level of education and language barriers (2/12) limiting parents' confidence in physicians. High trust levels significantly correlated with effective communication and perceived quality of care. Most effective interventions enhancing trust included communication and caring trust constructs (10/12) rather than competence and dependability (5/12). Parents' individual experiences, development of compassionate interactions, and practice of family-centered care appeared important in developing trust.

CONCLUSIONS

Improving communication and providing compassionate care, as well as encouraging a patient-centered approach, appear to be most effective in promoting trust in pediatric surgical and urgent settings. Our findings can guide future educational interventions towards strengthening parental trust and promoting child- and family-centered care in pediatric surgical settings.

Definitive Care for Severely Injured Children in Quebec

INTRODUCTION

Injury is the leading cause of death in children over the age of one in Canada, and remains the most common cause of death in Quebec pediatric patients. Indigenous communities are 3-4 times more likely to be affected by injuries than the national average. In Quebec, health centres can range from 30 to 1000 km away from the closest level I trauma center.

METHODS

Descriptive analysis and multiple logistic regression were performed for severely injured pediatric trauma patients received at the Montreal Children's Hospital (MCH) over a ten-year period. Outcomes were compared between regional groups in Quebec using forward sortation areas.

RESULTS

Two hundred and forty four pediatric patients presented to the MCH with major trauma between 2006 and 2016. Of those, 42% of patients resided in Montreal, 42% off-island, and 16% in Northern Quebec. Admission to the Intensive Care Unit (ICU) was required for 60% of off-island patients and 58% of Northern residents. The median length of hospital stay (LOS) was 5 days for off-island and 15 days for Northern patients. Most patients (78% off-island vs. 76% Northern Quebec) were discharged home. The overall mortality was 5%. In multiple regression analysis, residence in Northern Quebec was associated with increased incidence of longer than median length of stay compared to off-island patients (OR 2.78, 95%CI (1.12-7.29)) after adjusting for injury severity, operative intervention, age, and sex.

CONCLUSION

ICU admission rate was similar among Northern and off-island populations. Patients from Northern Quebec appeared to have longer-than-median hospital length of stay. In-hospital mortality was infrequent and limited to on-island and off-island populations. A further exploration of this data is required to identify the "trauma deserts" and advocate for children involved in trauma in all areas of Quebec.

A debriefing tool to acquire non-technical skills in trauma courses

Objective

The study reports the use of a nominal group technique (NGT) to evaluate the PEARLS Healthcare debriefing tool as a tool to foster non-technical skills in trauma simulation courses. Additionally, it introduces a debriefing card to be used in trauma courses.

Design

A nominal group technique was used to evaluate the main strategies for PEARLS. The experts had the opportunity to share their opinions in an online survey and online meeting.

Results

Seven participants participated in the nominal group. Based on the online survey results, the self-assessment debriefing strategy (from PEARLS) was rated 4.83/5 in relevance, the focused facilitation 5/5, and the provision of information 4.5/5. Participants felt that PEARLS was appropriate and useful for fostering non-technical skills: all the debriefing strategies contained in PEARLS were felt to be valid and worth using; and cue cards for the instructors were suggested to assist them in conducting structured formal debriefings. A specific debriefing tool for trauma scenarios was designed based on these suggestions, which is presented in this article.

Conclusion

A nominal group of experts in education, simulation, and trauma support PEARLS strategies for non-technical skills training in trauma courses.

•

Surgical programs overlook non-technical skills, possibly due to uncertainty regarding their instruction.

•

A structured debriefing tool can foster non-technical skills in trauma education.

•

This study introduces a debriefing card for trauma scenarios generated by a group of experts.

The use of artificial intelligence and virtual reality in doctor-patient risk communication: A scoping review

OBJECTIVES

While the development of artificial intelligence (AI) and virtual reality (VR) technologies in medicine has been significant, their application to doctor-patient communication is limited. As communicating risk is a challenging, yet essential, component of shared decision-making (SDM) in surgery, this review aims to explore the current use of AI and VR in doctor-patient surgical risk communication.

METHODS

The search strategy was prepared by a medical librarian and run in 7 electronic databases. Articles were screened by a single reviewer. Included articles described the use of AI or VR applicable to surgical risk communication between patients, their families, and the surgical team.

RESULTS

From 4576 collected articles, 64 were included in this review. Identified applications included decision support tools (15, 23.4%), tailored patient information resources (13, 20.3%), treatment visualization tools (17, 26.6%) and communication training platforms (19, 29.7%). Overall, these technologies enhance risk communication and SDM, despite heterogeneity in evaluation methods. However, improvements in the usability and versatility of these interventions are needed.

CONCLUSIONS

There is emerging literature regarding applications of AI and VR to facilitate doctor-patient surgical risk communication.

PRACTICE IMPLICATIONS

AI and VR hold the potential to personalize doctor-patient surgical risk communication to individual patients and healthcare contexts.

Application of Artificial Intelligence in Shared Decision Making: Scoping Review

Background

Artificial intelligence (AI) has shown promising results in various fields of medicine. It has the potential to facilitate shared decision making (SDM). However, there is no comprehensive mapping of how AI may be used for SDM.

Objective

We aimed to identify and evaluate published studies that have tested or implemented AI to facilitate SDM.

Methods

We performed a scoping review informed by the methodological framework proposed by Levac et al, modifications to the original Arksey and O'Malley framework of a scoping review, and the Joanna Briggs Institute scoping review framework. We reported our results based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) reporting guideline. At the identification stage, an information specialist performed a comprehensive search of 6 electronic databases from their inception to May 2021. The inclusion criteria were: all populations; all AI interventions that were used to facilitate SDM, and if the AI intervention was not used for the decision-making point in SDM, it was excluded; any outcome related to patients, health care providers, or health care systems; studies in any health care setting, only studies published in the English language, and all study types. Overall, 2 reviewers independently performed the study selection process and extracted data. Any disagreements were resolved by a third reviewer. A descriptive analysis was performed.

Results

The search process yielded 1445 records. After removing duplicates, 894 documents were screened, and 6 peer-reviewed publications met our inclusion criteria. Overall, 2 of them were conducted in North America, 2 in Europe, 1 in Australia, and 1 in Asia. Most articles were published after 2017. Overall, 3 articles focused on primary care, and 3 articles focused on secondary care. All studies used machine learning methods. Moreover, 3 articles included health care providers in the validation stage of the AI intervention, and 1 article included both health care providers and patients in clinical validation, but none of the articles included health care providers or patients in the design and development of the AI intervention. All used AI to support SDM by providing clinical recommendations or predictions.

Conclusions

Evidence of the use of AI in SDM is in its infancy. We found AI supporting SDM in similar ways across the included articles. We observed a lack of emphasis on patients’ values and preferences, as well as poor reporting of AI interventions, resulting in a lack of clarity about different aspects. Little effort was made to address the topics of explainability of AI interventions and to include end-users in the design and development of the interventions. Further efforts are required to strengthen and standardize the use of AI in different steps of SDM and to evaluate its impact on various decisions, populations, and settings.

Modeling the Scale-up of Surgical Services for Children with Surgically Treatable Congenital Conditions in Somaliland

BACKGROUND

Congenital conditions comprise a significant portion of the global burden of surgical conditions in children. In Somaliland, over 250,000 children do not receive required surgical care annually, although the estimated costs and benefits of scale-up of children's surgical services to address this disease burden is not known.

METHODS

We developed a Markov model using a decision tree template to project the costs and benefits of scale-up of surgical care for children across Somaliland. We used a proxy set of congenital anomalies across Somaliland to estimate scale-up costs using three different scale-up rates. The cost-effectiveness ratio and net societal monetary benefit were estimated using these models, supported by disability weights in existing literature.

RESULTS

Overall, we found that scale-up of surgical services at an aggressive rate (22.5%) over a 10-year time horizon is cost effective. Although the scale-up of surgical care for most conditions in the proxy set was cost effective, scale-up of hydrocephalus and spina bifida are not as cost effective as other conditions.

CONCLUSIONS

Our analysis concludes that it is cost effective to scale-up surgical services for congenital anomalies for children in Somaliland.

Moving shared decision-making forward in Iran

Although there have been breakthroughs in patients' rights and informed consent legislation in Iran during the last few years, there is still no policy regarding shared decision-making (SDM). Besides, SDM training and clinical implementation initiatives remain scarce within the country. In this article, we aim to provide an update on the current state of SDM in Iran and discuss future directions. Lastly, we propose an SDM model adapted to the Iranian context, through a consensus-building process with Iranian clinicians and SDM experts, to assist in its implementation in a culturally sensitive manner.

Use of a risk communication survey to prioritize family-valued outcomes and communication preferences for children undergoing outpatient surgical procedures

BACKGROUND

Effective shared decision-making in pediatric surgery requires clarity regarding which surgical outcomes are most important to patients and their families, and how they prefer to receive the information. Despite how essential this is for effective risk communication, little is known about the communication needs and preferences of patients and their families in elective pediatric surgery.

METHODS

We administered a mailed and online cross-sectional survey in English and French to 548 families before or after surgery for hernia/hydrocele repair or tonsillectomy/adenoidectomy between July 2019 and February 2021. The survey consisted of 22 questions eliciting most valued patient-reported outcomes (PROs) across 4 domains: health-related quality of life (5), functional status (5), symptoms and symptom burden (5), health behaviours and patient experience (7), as well as overall impressions (3), surgical risks (5), communication preferences (4), and demographic questions (16).

RESULTS

The survey was completed by 368 patient families (60 preoperative, 308 postoperative, response rate 67.2%). Most respondents (72%) indicated a significant desire to be informed on all listed PROs alongside surgical complications, and highly valued all functional and quality of life outcomes (92.9% & 89.8%, respectively). Preoperatively, patient families preferred to receive information in the form of pamphlets and websites, whereas postoperatively they preferred direct communication.

CONCLUSION

Families value functional and quality of life PROs as much as clinical outcomes, and increasingly seek more contemporary (electronic) means of risk communication than we currently offer. This data will inform the development of mobile tools for personalized communication in pediatric surgery.

Exploring the roles of artificial intelligence in surgical education: A scoping review

BACKGROUND

Technology-enhanced teaching and learning, including Artificial Intelligence (AI) applications, has started to evolve in surgical education. Hence, the purpose of this scoping review is to explore the current and future roles of AI in surgical education.

METHODS

Nine bibliographic databases were searched from January 2010 to January 2021. Full-text articles were included if they focused on AI in surgical education.

RESULTS

Out of 14,008 unique sources of evidence, 93 were included. Out of 93, 84 were conducted in the simulation setting, and 89 targeted technical skills. Fifty-six studies focused on skills assessment/classification, and 36 used multiple AI techniques. Also, increasing sample size, having balanced data, and using AI to provide feedback were major future directions mentioned by authors.

CONCLUSIONS

AI can help optimize the education of trainees and our results can help educators and researchers identify areas that need further investigation.

Identifying Barriers in Access to Care for Head and Neck Cancer Patients: A Field Study in Dakar

OBJECTIVES/HYPOTHESIS

To identify barriers in access to care for head and neck cancer (H&NC) patients in low- and middle-income countries (LMICs), specifically within Dakar, Senegal, using both quantitative and qualitative data.

STUDY DESIGN

Descriptive observational study.

METHODS

Patients with H&NC were selected from two independent university hospitals in Dakar, Senegal. A mixed-methods descriptive study was performed using a specifically tailored questionnaire and a focused ethnographic qualitative approach to identify factors that delay patient presentation, referral, and treatment. Quantitative data were analyzed using descriptive statistics and qualitative using a deductive approach based on a systematic review of the literature.

RESULTS

Thirty-three patients with a mean age of 57.8 years were included. Presentation delay was 5.7 months, mainly attributed to cost of consultation (39%), waiting time at doctor's office (15%), and distance to healthcare facility (12%). Referral delay greater than 3 months was observed in 60% of participants, secondary to misdiagnosis and lack of appropriate referral. Treatment delay was associated with limited local treatment capacity and securing cost of treatment. Cost of transportation impacted all delays.

CONCLUSIONS

This work used an evidence-based approach to identify barriers in access to care for H&NC patients in sub-Saharan Africa. It suggests the feasibility and transferability of this methodology which combined a quantitative approach based on the literature with a qualitative analysis. Insight provided by this study will be used to guide development of implementation strategies for early detection of H&NC in LMICs.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo

BACKGROUND

Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging.

METHODS

This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care.

RESULTS

Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment.

CONCLUSIONS

Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Systematic review of grading systems for adverse surgical outcomes

Background

Grading scales for adverse surgical outcomes have been poorly characterized to date. The primary aim of this study was to conduct a systematic review to enumerate the various frameworks for grading adverse postoperative outcomes; our secondary objective was to outline the properties of each grading system, identifying its strengths and weaknesses.

Methods

We searched 9 databases (Africa Wide Information, Biosis, Cochrane, Embase, Global Health, LILACs, Medline, PubMed and Web of Science) from 1992 (the year the Clavien–Dindo classification system was developed) until Mar. 2, 2017, for studies that aimed to develop or improve on an already existing generalizable system for grading adverse postoperative outcomes. Study selection was duplicated as per PRISMA recommendations. Procedure-specific grading systems were excluded. We assessed the framework, strengths and weaknesses of the systems qualitatively.

Results

We identified 9 studies on 8 adverse outcome grading systems with frameworks generalizable to any surgical procedure. Most systems have not been widely incorporated in the literature. Seven of the 8 systems were produced without including patients’ perspectives. Four allowed the derivation of a composite morbidity score, which had limited tangible significance for patients.

Conclusion

Although each instrument identified offered its own advantages, none satisfied the need for a patient-centred tool capable of generating a composite score of all possible postoperative adverse outcomes (complications, sequelae and failure) that enables comparison of noninterventional and surgical management of disease. There is a need for development of a more comprehensive, patient-centred grading system for adverse postoperative outcomes.

Comparison of the Pediatric Resuscitation and Trauma Outcome (PRESTO) Model and Pediatric Trauma Scoring Systems in a Middle-Income Country

BACKGROUND

The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk-adjusted mortality after injury in low- and middle-income countries (LMICs). We sought to validate PRESTO using data from a middle-income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age-adjusted shock index (SIPA).

METHODS

We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model-age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high-income country (HIC)-validated optimal threshold was compared to MIC-validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in-hospital death using trauma scoring systems was compared using ROC analysis.

RESULTS

Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0-25.7%, AUROC 0.93). Using the HIC-validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in-hospital death compared to PTS and SIPA (all p < 0.01).

CONCLUSION

PRESTO can be applied in MIC settings and discriminates between children at risk for in-hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings.

Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

BACKGROUND

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.

METHODS

Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child's age, gender, village type, household income level, region, and household size.

RESULTS

Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.

CONCLUSION

Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

Barriers in Access to Care for Patients With Head and Neck Cancer in Resource-Limited Settings: A Systematic Review

Importance

The identification of the barriers to care for patients with head and neck cancer in low-income and lower-middle-income countries is a crucial first step toward the identification of targets for developing and implementing cost-effective programs to increase awareness, prevention, and treatment of head and neck cancer in this setting.

Objective

To identify the barriers to care for patients presenting with head and neck cancer in low-income and lower-middle-income countries.

Evidence Review

Nine databases were searched from their inception to December 21, 2017: Africa-Wide Information, the Cochrane Library, Embase, Global Health, LILACS, MEDLINE, BIOSIS Previews, and Web of Science. Search terms referred to head and neck cancer, barriers to care, and low- and lower-middle-income countries, and no temporal and linguistic restrictions were imposed. Articles were reviewed by 2 independent investigators, and differences in inclusion were resolved by discussion. Bibliographies of all included articles were screened, and all relevant articles were reviewed using the same procedure. Quantitative articles were assessed using the Methodological Index for Non-Randomized Studies tool, and articles with qualitative data used the Critical Appraisal Skills Programme qualitative checklist. This systematic review was registered in PROSPERO (registration No. CRD42018092448) and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.

Findings

Of the 44 articles selected for review, 18 (41%) met the selection criteria. All articles reported quantitative results, and 3 (17%) added some qualitative material to the study design. Most (11 [61%]) of the studies originated from India. A total of 41 different barriers to care were identified, with low level of education (cited in 8 articles [44%]), low socioeconomic status (in 4 articles [22%]), and lack of knowledge about head and neck cancer (in 3 articles [17%]) being statistically associated with a delayed presentation. Misunderstanding of signs and symptoms, use of alternative medicine, and inability to access health care were other barriers discussed in the qualitative articles.

Conclusions and Relevance

This systematic review highlighted the lack of both qualitative and quantitative information for patients with head and neck cancer in low-income and lower-middle-income countries. The findings suggest that integrating the barriers to care with information from patient lives may identify the clinical and social relevance of these barriers and guide future research.

The burden of waiting: wait times for pediatric surgical procedures in Quebec and compliance with national benchmarks

Background

Wait time information and compliance with national guidelines are limited to a few adult conditions in the province of Quebec. We aimed to assess compliance with Paediatric Canadian Access Targets for Surgery (P-CATS) guidelines and determine the burden incurred due to waiting for 3 common elective surgical conditions (inguinal hernia, cryptorchidism and hypospadias) in a pediatric population.

Methods

We carried out a population-based retrospective cohort study of randomly selected children residing in Quebec without complex chronic medical conditions, using administrative databases belonging to the Régie de l’assurance maladie du Québec for the period 2010–2013. Disability-adjusted life years (DALYs) were calculated to measure the burden due to waiting. Multivariate forward regression identified risk factors for compliance with national guidelines.

Results

Surgical wait time information was assessed for 1515 patients, and specialist referral wait time was assessed for 1389 patients. Compliance with P-CATS benchmarks was 76.6% for seeing a specialist and 60.7% for receiving surgery. Regression analysis identified older age (p < 0.0001) and referring physician specialty (p = 0.001) as risk factors affecting specialist referral wait time target compliance, whereas older age (p = 0.040), referring physician specialty (p = 0.043) and surgeon specialty (p = 0.002) were significant determinants in surgical wait time compliance. The total burden accrued due to waiting beyond benchmarks was 35 DALYs.

Conclusion

Our results show that provincial compliance rates with wait time benchmarks are still inadequate and need improvement. Patient age and physician specialty were both found to have significant effects on wait time target compliance.

Reduction of spondylolisthesis and sagittal balance correction by anterior lumbar interbody fusion (ALIF)

PURPOSE

Long time recognized as a cause of lumbar stenosis, degenerative spondylolisthesis has an evolution in interrelation with sagittal balance. This study aimed to assess the role of ALIF in correcting the sagittal balance in patients with degenerative spondylolisthesis.

MATERIAL AND METHODS

Twenty patients aged between 47 and 70 years were operated between July 2011 and September 2014 for degenerative spondylolisthesis by ALIF. The pre-operative and post-operative valid standing full spine radiographs were reviewed retrospectively. Clinical and radiological evaluations were conducted pre-operatively and postoperatively at one year and five years.

RESULTS

Lumbar lordosis (LL) was measured to 41.16 ± 14.25° pre-operatively and 47.27 ± 11.25° post-operatively (p > 0.05). At one year was 49.76 ± 13.31° and at five years 46.93 ± 9.26° (p > 0.05). Mean gain of lordosis after ALIF at index level was calculated to 8 ± 1.6° [4-12°].

CONCLUSIONS

ALIF offers a good reduction of the slipped vertebra providing good conditions for fusion and is an efficient surgical technique to recreate the sagittal spine balance.

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

BACKGROUND

The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.

METHODS

In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.

RESULTS

The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.

CONCLUSION

We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.

Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland

BACKGROUND

Delayed access to surgical care for congenital conditions in low- and middle-income countries is associated with increased risk of death and life-long disabilities, although the actual burden of delayed access to care is unknown. Our goal was to quantify the burden of disease related to delays to surgical care for children with congenital surgical conditions in Somaliland.

METHODS

We collected data from medical records on all children (n = 280) receiving surgery for a proxy set of congenital conditions over a 12-month time period across all 15 surgically equipped hospitals in Somaliland. We defined delay to surgical care for each condition as the difference between the ideal and the actual ages at the time of surgery. Disability-adjusted life years (DALYs) attributable to these delays were calculated and compared by the type of condition, travel distance to care, and demographic characteristics.

RESULTS

We found long delays in surgical care for these 280 children with congenital conditions, translating to a total of 2970 attributable delayed DALYs, or 8.4 avertable delayed DALYs per child, with the greatest burden among children with neurosurgical and anorectal conditions. Over half of the families seeking surgical care had to travel over 2 h to a surgically equipped hospital in the capital city of Hargeisa.

CONCLUSIONS

Children with congenital conditions in Somaliland experience substantial delays to surgical care and travel long distances to obtain care. Estimating the burden of delayed surgical care with avertable delayed DALYs offers a powerful tool for estimating the costs and benefits of interventions to improve the quality of surgical care.

Derivation of a complication burden score based on disability-adjusted life years to assess patient burden following surgery: a pilot study

BACKGROUND

Comparing adverse outcomes following alternative surgical interventions is a complex process for both patients and providers. Disability-adjusted life years (DALYs) are used globally as a quantitative indicator of burden of disease. However, DALYs have not been applied to the burden of postoperative complications. This study explores the feasibility and utility of DALYs in measuring the burden of postoperative complications, using 2 pediatric surgical procedures as a test model.

METHODS

A literature review was undertaken of postoperative complications following pediatric inguinal hernia repair and intestinal atresia repair. Relevant studies were included, and incidence rates and durations of all key complications were identified. Using existing disability weights of equivalent health states to the complications, we estimated the burden in DALYs of each complication. These estimates were combined into a unitary procedure-specific complication burden score.

RESULTS

The key complications contributing to the postoperative burden following inguinal hernia repair were recurrence (0.016 DALYs), hydrocele (0.010), metachronous hernia (0.014) and port-site hernia (0.012). In the case of intestinal atresia repair, death (6.278), reoperation (12.100), stenosis (5.025) and anastomotic stricture (5.327) accounted for most of the postoperative DALYs. The complication burden score was 0.06 DALYs for inguinal hernia and 36.86 for intestinal atresia repair.

CONCLUSION

As a proof of concept, this study supports the feasibility of using DALYs to derive a complication burden score following surgical intervention, and to our knowledge it represents the first application of burden of disease metrics to postoperative adverse outcomes. Future studies should focus on deriving de novo disability weights for common postoperative complications and adverse outcomes.

Calibration and validation of the pediatric resuscitation and trauma outcome model among injured children in Rwanda

BACKGROUND

Trauma is a leading cause of mortality in low- and middle-income countries. The Pediatric Resuscitation and Trauma Outcomes (PRESTO) model uses six low-tech variables available at point of care in resource-limited environments to predict in-hospital mortality of injured children. This model was never calibrated and validated in a low-income country. We aimed to calibrate the model's coefficients and compare its performance against the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) using data from a low-income country.

STUDY DESIGN

Data from 2011 to 2015 in the prospectively-maintained Rwanda Injury Registry were reviewed after ethical approval was obtained. Patients were included for analysis if they were referred or admitted for traumatic injury, were younger than 15 years and if hospital outcomes were recorded. The variables in the PRESTO model include age, hypotension, heart rate, neurological status, oxygen saturation and airway intervention. The outcome of interest was in-hospital death. After calibration, Receiver-Operating-Characteristic curves were constructed to compare the area-under-curve (AUC) of PRESTO, RTS, and KTS with imputation of missing data. Comparisons of the relative AUC's were performed using Delong's test after bootstrapping in the full cohort and in a subset of patients <5 years-old.

RESULTS

There were 113 in-hospital deaths out of 1695 included patients (6.7%). The AUC for the PRESTO model was 0.90 (95% CI [0.82-0.91]), higher than for RTS (0.77, 95% CI [0.80-0.97], p < 0.01) but not statistically different from KTS (0.89, 95% CI [0.72-0.82], p = 0.856). In the under-five cohort, the PRESTO model AUC was 0.84 (95% CI [0.75-0.92]), significantly higher than RTS (0.73 95% CI [0.64-0.81], p < 0.01) and KTS (0.58, 95% CI [0.50-0.66], p < 0.01).

CONCLUSION

PRESTO appears to be the superior benchmarking tool for pediatric patients in a low- and middle-income country context. The PRESTO score outperforms the KTS in children <5 years of age. Further validation of the PRESTO model is needed from other low- and middle-income settings.

LEVEL OF EVIDENCE

Level III: case-control (prognostic) study.

Shared decision making in surgery: A scoping review of the literature

BACKGROUND

Shared decision making (SDM) has been increasingly implemented to improve health-care outcomes. Despite the mixed efficacy of SDM to provide better patient-guided care, its use in surgery has not been studied. The aim of this study was to systematically review SDM application in surgery.

DESIGN

The search strategy, developed with a medical librarian, included nine databases from inception until June 2019. After a 2-person title and abstract screen, full-text publications were analysed. Data collected included author, year, surgical discipline, location, study duration, type of decision aid, survey methodology and variable outcomes. Quantitative and qualitative cross-sectional studies, as well as RCTs, were included.

RESULTS

A total of 6060 studies were retrieved. A total of 148 were included in the final review. The majority of the studies were in plastic surgery, followed by general surgery and orthopaedics. The use of SDM decreased surgical intervention rate (12 of 22), decisional conflict (25 of 29), and decisional regret (5 of 5), and increased decisional satisfaction (17 of 21), knowledge (33 of 35), SDM preference (13 of 16), and physician trust (4 of 6). Time increase per patient encounter was inconclusive. Cross-sectional studies showed that patients prefer shared treatment and surgical treatment varied less. The results of SDM per type of decision aid vary in terms of their outcome.

CONCLUSION

SDM in surgery decreases decisional conflict, anxiety and surgical intervention rates, while increasing knowledge retained decisional satisfaction, quality and physician trust. Surgical patients also appear to prefer SDM paradigms. SDM appears beneficial in surgery and therefore worth promoting and expanding in use.