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Klazura G, Kayima P, Situma M, Musinguzi E, Mugarura R, Nyonyintono J, Yap A, Cope J, Akello R, Kiwanuka E, Odonkara M, Okellowange C, Adongpiny J, Lakwanyero D, Atim P, Cadrine AP, Olara J, Boppana A, Laverde R, d'Agostino S, Cigliano B, Ozgediz D, Sims T, Kisa P. Pediatric Surgery Collaboration in Uganda, the Benefits of Long Term Partnerships at Regional Referral Hospitals. Res Sq 2024:rs.3.rs-4332253. [PMID: 38766237 PMCID: PMC11100894 DOI: 10.21203/rs.3.rs-4332253/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background: In 2022 there were only seven pediatric surgeons in Uganda, but approximately 170 are needed. Consequently, Ugandan general surgeons treat most pediatric surgical problems at regional hospitals. Accordingly, stakeholders created the Pediatric Emergency Surgery Course, which teaches rural providers identification, resuscitation, treatment and referral of pediatric surgical conditions. In order to improve course offerings and better understand pediatric surgery needs we collected admission and operative logbook data from four participating sites. One participating site, Lacor Hospital, rarely referred patients and had a much higher operative volume. Therefore, we sought to understand the causes of this difference and the resulting economic impact. Methods: Over a four-year period, data was collected from logbooks at four different regional referral hospitals in Uganda. Patients < 18 years old with a surgical diagnosis were included. Patient LOS, referral volume, age, and case type were compared between sites and DALYs were calculated and converted into monetary benefit. Results: Over four sites, 8,615 admissions, and 5,457 cases were included. Lacor patients were younger, had a longer length of stay, and were referred less. Additionally, Lacor's long-term partnerships with a high-income country institution, a missionary organization, and visiting Ugandan and international pediatric surgeons were unique. In 2018, the pediatric surgery case volume was: Lacor (967); Fort Portal (477); Kiwoko (393); and Kabale (153), resulting in a substantial difference in long-term monetary health benefit. Conclusion: Long-term international partnerships may advance investments in surgical infrastructure, workforce, and education in low- and middle-income countries. This collaborative model allows stakeholders to make a greater impact than any single institution could make alone.
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Grant CL, Tumuhimbise C, Ninsiima C, Robinson T, Eurich D, Bigam D, Situma M, Saleh A. Corrigendum to "Improved documentation following the implementation of a trauma registry: A means of sustainability for trauma registries in low- and middle-income countries" [Injury, 52 (2021) pages 2672-2676]. Injury 2024; 55:111448. [PMID: 38457998 DOI: 10.1016/j.injury.2024.111448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Affiliation(s)
- Chantalle L Grant
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, T6G 2B7, Canada.
| | - Christine Tumuhimbise
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Consolet Ninsiima
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tessa Robinson
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 690 Water Street, Simcoe, Ontario, N3Y 4K1, Canada
| | - Dean Eurich
- School of Public Health, University of Alberta, 2-040F Li Ka Shing Centre For Research, 11203 - 87 Ave NW, T6G 2H5, Edmonton AB Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
| | - Martin Situma
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Health Research Methods, Evidence, & Impact, McMaster University, 690 Water Street, Simcoe, Ontario, N3Y 4K1, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, T6G 2B7, Canada
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Klazura G, Stephens C, Musinguzi E, Mugarura R, Nyonyintono J, Laverde R, Nimanya S, Situma M, Bua E, Yap A, Sims T, Ozgediz D, Kisa P. Pediatric Emergency Surgery Course in Uganda: Long-Term Follow-Up and Insights From Further Dissemination. J Surg Res 2024; 295:837-845. [PMID: 38194867 PMCID: PMC10922965 DOI: 10.1016/j.jss.2023.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 11/13/2023] [Accepted: 11/18/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Approximately 170 pediatric surgeons are needed for the 24 million children in Uganda. There are only seven. Consequently, general surgeons manage many pediatric surgical conditions. In response, stakeholders created the Pediatric Emergency Surgery Course (PESC) for rural providers, given three times in 2018-2019. We sought to understand the course's long-term impact, current pediatric surgery needs, and determine measures for improvement. METHODS In October 2021, we distributed the same test given in 2018-2019. Student's t-test was used to compare former participants' scores to previous scores. The course was delivered again in May 2022 to new participants. We performed a quantitative needs assessment and also conducted a focus group with these participants. Finally, we interviewed Surgeon in Chiefs at previous sites. RESULTS Twenty three of the prior 45 course participants re-took the PESC course assessment. Alumni scored on average 71.9% ± 18% correct. This was higher from prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018-2019 postcourse scores 71.9% ± 14%. Fifteen course participants completed the needs assessment. Participants had low confidence managing pediatric surgical disease (median Likert scale ≤ 3.0), 12 of 15 participants endorsed lack of equipment, and eight of 15 desired more educational resources. Qualitative feedback was positive: participants valued the pragmatic lessons and networking with in-country specialists. Further training was suggested, and Chiefs noted the need for more trained staff like anesthesiologists. CONCLUSIONS Participants favorably reviewed PESC and retained knowledge over three years later. Given participants' interest in more training, further investment in locally derived educational efforts must be prioritized.
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Affiliation(s)
- Greg Klazura
- Department of Surgery, University of Illinois at Chicago, Loyola University Medical Center.
| | - Caroline Stephens
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia
| | | | | | | | - Ruth Laverde
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia
| | | | | | | | - Ava Yap
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia
| | - Thomas Sims
- Department of Surgery, University of Illinois at Chicago
| | - Doruk Ozgediz
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia
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Binde AH, Oyania F, Ullrich S, Situma M, Kotagal M, Mulogo EM. Hirschsprung disease: a cost analysis study of the direct, indirect costs and financial coping strategies for the surgical management in Western Uganda. Pediatr Surg Int 2024; 40:37. [PMID: 38252165 DOI: 10.1007/s00383-023-05571-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Surgical management of Hirschsprung disease (HD) in low- and middle-income countries is typically a staged procedure, necessitating multiple hospitalizations and clinic visits increasing family financial burden. Currently, there is limited information on the costs borne by caretakers of children with Hirschsprung disease seeking surgical intervention. This study seeks to measure the costs and economic burden of surgical treatment for Hirschsprung disease in western Uganda. METHODS A cross-sectional study using cost analysis was conducted among caretakers of patients who completed surgical treatment of HD between January 2017 and December 2021 at two hospitals in western Uganda. The average direct and indirect costs incurred by caretakers presenting at a public and private hospital were computed. RESULTS A total of 69 patients (M: F = 7:1) were enrolled in the study. The median age at diagnosis was 60.5 (IQR 3-151.25) days for children and two-staged pull-through procedure was the common surgery performed. The mean overall cost for treatment was US $960 (SD = $720), with the majority of costs coming from direct medical costs. Nearly half (48%) of participants resorted to distress financing to finance their child's surgical care. The overwhelming majority of patients (n = 64, 93%) incurred catastrophic expenditure from the total costs of surgery for HD, and 97% of participants fell below the international poverty line at the time treatment was completed. CONCLUSION Despite the availability of 'free care' from government hospital and non-profit services, this study found that surgical management of Hirschsprung disease imposed substantial cost burden on families with Hirschsprung disease patients.
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Affiliation(s)
| | - Felix Oyania
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Martin Situma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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Klazura G, Situma M, Musinguzi E, Mugarura R, Nyonyintono J, Yap A, Stephens CQ, Ullrich S, Kakembo N, Sekabira J, Ssemeju A, Bwesigye M, Muzaki D, Sims T, Proscovia N, Mbambu J, Kwikiriza D, Arinda F, Ozgediz D, Kisa P. The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda. J Pediatr Surg 2024; 59:146-150. [PMID: 37914591 PMCID: PMC10842949 DOI: 10.1016/j.jpedsurg.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE The Pediatric Emergency Surgery Course (PESC) trains rural Ugandan providers to recognize and manage critical pediatric surgical conditions. 45 providers took PESC between 2018 and 2019. We sought to assess the impact of the course at three regional hospitals: Fort Portal, Kabale, and Kiwoko. METHODS We conducted a retrospective cohort study. Diagnosis, procedure, and patient outcome data were collected twelve months before and after PESC from admission and theater logbooks. We also assessed referrals from these institutions to Uganda's two pediatric surgery hubs: Mulago and Mbarara Hospitals. Wilcoxon rank-sum and Pearson's chi-squared tests compared pre- and post-PESC measures. Interrupted time-series-analysis assessed referral volume before and after PESC. RESULTS 1534 admissions and 2148 cases were documented across the three regional hospitals. Kiwoko made 539 referrals, while pediatric surgery hubs received 116 referrals. There was a statistically significant immediate increase in the number of referrals from Fort Portal, from 0.5 patients/month pre-PESC to 0.8 post-PESC (95 % CI 0.03-1.51). Moving averages of the combined number of pyloromyotomy, intussusception reductions, and hernia repairs at the rural hospitals also increased post-course. Neonatal time to referral and referred patient age were significantly lower after PESC delivery. CONCLUSION Our data suggest that PESC increased referrals to tertiary centers and operative volume of selected cases at rural hospitals and shortened time to presentation at sites receiving referrals. PESC is a locally-driven, validated, clinical education intervention that improves timely care of pediatric surgical emergencies and merits further support and dissemination. TYPE OF STUDY Retrospective Cohort Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Greg Klazura
- University of Illinois at Chicago Department of Surgery, Loyola University Medical Center, United States.
| | | | | | | | | | - Ava Yap
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia, United States
| | - Caroline Q Stephens
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia, United States
| | | | | | | | | | | | | | - Thomas Sims
- University of Illinois at Chicago Department of Surgery, United States
| | | | | | | | | | - Doruk Ozgediz
- University of California San Francisco, Center for Health Equity in Surgery and Anesthesia, United States
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Oyania F, Kotagal M, Wesonga AS, Nimanya SA, Situma M. Pull-Through for Hirschsprung's Disease: Insights for Limited-Resource Settings From Mbarara. J Surg Res 2024; 293:217-222. [PMID: 37797389 DOI: 10.1016/j.jss.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION In many resource-limited settings, patients with Hirschsprung's Disease (HD) undergo initial diverting colostomy, followed by pull-through, and finally, colostomy closure. This approach allows for decompression of dilated and thickened bowel and improved patient nutritional status. However, this three-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life. Our aim was to determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages. METHODS Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course and 3-mo outpatient course were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study. RESULTS Of the 20 children, 17 were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range [IQR] 10-12.75), 0.9 y (IQR 0.25-2.8), and 2.08 y (IQR 1.28-2.75), respectively. Mean duration with colostomy before pull-through was 1.1 y (standard deviation 1.51). Median hospital length of stay was 6 d (IQR 5-7). Early complications included anastomotic leak (n = 1), perianal skin excoriation (n = 2), surgical site skin infection (n = 3), and fascial dehiscence (n = 1). Longer-term complications included stricture (n = 1, 5%) and enterocolitis (n = 2, 10%). CONCLUSIONS In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the quality of life and economic impact of this change in management for HD patients.
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Affiliation(s)
- Felix Oyania
- Mbarara University of Science and Technology, Uganda.
| | | | | | | | - Martin Situma
- Mbarara University of Science and Technology, Uganda
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Trinidad S, Oyania F, Bingana C, Nuwagaba I, Obermeyer M, Odongo C, Kotagal M, Situma M. Pilot bowel management program at Mbarara Hospital, Uganda. Pediatr Surg Int 2023; 39:292. [PMID: 37962686 DOI: 10.1007/s00383-023-05574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Children with Hirschsprung's disease (HD) and anorectal malformations (ARM) may benefit from a bowel management program (BMP) to treat constipation and fecal incontinence. This study describes a pilot BMP in Uganda. METHODS Patients treated for HD or ARM were recruited for the BMP. Local staff underwent training and progressively took over decision-making. The rates of patient involuntary bowel movements (IBMs) and provider confidence were evaluated pre- and post-BMP with questionnaires. The results were compared with Fischer's exact test. RESULTS Ten staff-2 surgeons, 6 nurses and 2 physiotherapists-and 12 patients participated. Patient median age was 4.5 years (IQR 3-6.6) and ten were male. Ten reported at least daily IBMs prior to the BMP. All patients underwent a clean-out. The parents were then taught to perform daily enemas or irrigations. Specific regimens were determined by patient history and imaging and titrated throughout the BMP. There were differences in the rates of both daytime and nighttime IBMs before and after the BMP (p = 0.0001 and 0.002, respectively). All staff reported increased confidence. CONCLUSIONS We describe the first BMP in Uganda. BMPs can successfully treat constipation and fecal incontinence in low-income countries, although there are challenges with resources and follow-up.
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Affiliation(s)
- Stephen Trinidad
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
- , 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Felix Oyania
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Maria Obermeyer
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Martin Situma
- Mbarara University of Science and Technology, Mbarara, Uganda
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Rapolti D, Kisa P, Situma M, Nico E, Lobe T, Sims T, Ozgediz D, Klazura G. The Creation of a Pediatric Surgical Checklist for Adult Providers. Res Sq 2023:rs.3.rs-3269257. [PMID: 37790469 PMCID: PMC10543282 DOI: 10.21203/rs.3.rs-3269257/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Purpose To address the need for a pediatric surgical checklist for adult providers. Background Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications. Methods Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias. Results 42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies. Conclusion The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes. Funding Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.
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Affiliation(s)
- Diana Rapolti
- University of Illinois Hospital and Health Sciences System
| | | | | | - Elsa Nico
- University of Illinois Hospital and Health Sciences System
| | - Thom Lobe
- University of Illinois Hospital and Health Sciences System
| | - Thomas Sims
- University of Illinois Hospital and Health Sciences System
| | | | - Greg Klazura
- University of Illinois Hospital and Health Sciences System
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Kakembo N, Grabski DF, Situma M, Ajiko M, Kayima P, Nyeko D, Shikanda A, Okello I, Tumukunde J, Nabukenya M, Ogwang M, Kisa P, Muzira A, Ruzgar N, Fitzgerald TN, Sekabira J, Ozgediz D. Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis. J Surg Res 2023; 286:23-34. [PMID: 36738566 DOI: 10.1016/j.jss.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 12/05/2022] [Accepted: 12/24/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.
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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.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Hospital, Mbarara, Uganda
| | - Margaret Ajiko
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Peter Kayima
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - David Nyeko
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Anne Shikanda
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Innocent Okello
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Ogwang
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Nensi Ruzgar
- Yale University School of Medicine, New Haven, Connecticut
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John Sekabira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California, San Francisco, California
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Oyania F, Commander SJ, Mugarura R, Situma M. 3-year-old with Mayer–Rokitansky–Küster–Hauser syndrome and anorectal malformation: A case report. Int J Surg Case Rep 2023; 106:108120. [PMID: 37060764 PMCID: PMC10139876 DOI: 10.1016/j.ijscr.2023.108120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Anorectal malformation is associated with congenital anomalies affecting other body systems, including vertebral, anorectal, cardiac, tracheoesophageal, renal and limb defects. Mayer-Rokitansky-Küster-Hauser syndrome is a collection of several congenital defects in the female reproductive system, including congenital agenesis of the uterus, cervix, and upper two-thirds of the vagina, that could be associated with anorectal malformation. CASE PRESENTATION A 3-year old female initially treated for vestibular fistula as she had only two orifices, who intra-operatively was discovered to have Mayer-Rokitansky-Küster-Hauser syndrome associated with cardiac, skeletal (foot), and anorectal anomalies. CLINICAL DISCUSSION The diagnosis Mayer-Rokitansky-Küster-Hauser syndrome should be considered in a female patient presenting with anorectal malformation especially when two orifices are encountered in the perineum. Mayer-Rokitansky-Küster-Hauser syndrome can be associated with vestibular or rectovaginal fistula, of which the former is the most common type that coexists. Treatment involves surgical and nonsurgical approaches, Surgically a new cavity is created to replace the vagina with a mucous membrane lined canal such as a bowel segment. CONCLUSION This case demonstrates that anorectal malformation with Mayer-Rokitansky-Küster-Hauser syndrome can be mistaken for a vestibular fistula, even in specialized centers like ours. Therefore, a high index of suspicion should be noted especially when examination under anesthesia confirms only two orifices in the perinium.
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Affiliation(s)
- Felix Oyania
- Mbarara University of Science and Technology, Department of Surgery, Pediatric Surgical Unit, Uganda; Center for Health Equity in Surgery and Anesthesia, UCSF, United States of America; Multi-morbidity research capacity initiative (MURCI) Research training fellowship, Mbarara University of Science and Technology, Uganda.
| | | | | | - Martin Situma
- Mbarara Regional Referral Hospital and Mbarara University of Science and Technology, Department of Surgery, Head of Pediatric Surgical Unit, Uganda
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Ekuk E, Odongo CN, Tibaijuka L, Oyania F, Egesa WI, Bongomin F, Atwiine R, Acan M, Situma M. One year overall survival of wilms tumor cases and its predictors, among children diagnosed at a teaching hospital in South Western Uganda: a retrospective cohort study. BMC Cancer 2023; 23:196. [PMID: 36864435 PMCID: PMC9979450 DOI: 10.1186/s12885-023-10601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/01/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Wilms tumor (WT) is the second most common solid tumor in Africa with both low overall survival (OS) and event-free survival (EFS) rates. However, no known factors are predicting this poor overall survival. OBJECTIVE The study was to determine the one-year overall survival of WT cases and its predictors among children diagnosed in the pediatric oncology and surgical units of Mbarara regional referral hospital (MRRH), western Uganda. METHODOLOGY Children's treatment charts and files diagnosed and managed for WT were retrospectively followed up for the period between January 2017 to January 2021. Charts of children with histologically confirmed diagnoses were reviewed for demographics, clinical and histological characteristics, as well as treatment modalities. RESULTS One-year overall survival was found to be 59.3% (95% CI: 40.7-73.3), with tumor size greater than 15 cm (p 0.021) and unfavorable WT type (p 0.012) being the predominant predictors. CONCLUSION Overall survival (OS) of WT at MRRH was found to be 59.3%, and predictive factors noted were unfavorable histology and tumor size greater than 115 cm.
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Affiliation(s)
- Eddymond Ekuk
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.
| | - Charles Newton Odongo
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.,Department of Anatomy, Faculty of Medicine Soroti University, Soroti, Uganda
| | - Leevan Tibaijuka
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Felix Oyania
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Walufu Ivan Egesa
- Department of Pediatrics, Faculty of Clinical Medicine and Dentistry, Kampala International, Kampala, Uganda
| | - Felix Bongomin
- Department of Microbiology, Mycology, and Immunology, Internal Medicine Gulu University, Gulu, Uganda
| | - Raymond Atwiine
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Moses Acan
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
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Oyania F, Mugarura R, Newton odongo C, Commander SJ, Situma M. Esophageal foreign body retrieved by cervical esophagotomy four years after ingestion. Journal of Pediatric Surgery Case Reports 2023. [DOI: 10.1016/j.epsc.2023.102580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Odongo CN, Oyania F, Godier-Furnemont A, Moro J, Situma M. Neonatal presentation of transected sigmoid colon following umbilical cord clamping: Hernia of umbilical cord. Journal of Pediatric Surgery Case Reports 2023. [DOI: 10.1016/j.epsc.2022.102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Grant CL, Ali AM, Oyania F, Oloya P, Robinson T, Cameron B, Situma M, Eurich D, Bigam D, Saleh A. Development and evaluation of a mobile application trauma registry for use in low- and middle-income countries. Trauma 2022. [DOI: 10.1177/14604086221129385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction Trauma registries are a means for improving trauma care in low- and middle-income countries, though a number of challenges for the sustainability of these trauma registries exist. Mobile health applications represent a promising technology for low- and middle-income country trauma registries. The development, implementation and evaluation of a mobile application trauma registry for use at the Mbarara Regional Referral Hospital, Uganda is demonstrated. Methods A paper-based trauma registry was implemented at the Mbarara Regional Referral Hospital. Based on feedback from local stakeholders, this was developed into an open-source mobile application version of the trauma registry. The mobile application was evaluated by 17 healthcare workers using a modified Unified Theory of Acceptance and Use of Technology questionnaire and qualitative analysis. Results Unified Theory of Acceptance and Use of Technology scores showed the majority of participants responding positively to the major constructs of Performance Expectancy, Effort Expectancy, Social Influence and Facilitating Conditions, with mean Likert scores (out of 7) of 6.41 (±1.43), 6.25 (±1.41), 5.44 (±1.43) and 5.32 (±1.99), respectively. There was also a young average user age (29.1 years). Qualitative analysis identified response themes of ease of use, efficiency and potential for future research and clinical use; users also suggested expansion of the type of platforms the application was available on. Conclusion Though a number of challenges exist for sustaining trauma registries in low- and middle-income countries, substantial involvement of local stakeholders and responsiveness to feedback should be used to facilitate the use of these technologies in developing countries. This study demonstrates a potential methodology for developing and evaluating trauma registry technologies for use in low- and middle-income countries.
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Affiliation(s)
| | - Ali Mohamad Ali
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Felix Oyania
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Patrick Oloya
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tessa Robinson
- Department of Health Research Methods, Evidence, & Impact, Health Research Methodology Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Brian Cameron
- Department of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Martin Situma
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dean Eurich
- School of Public Health, University of Alberta, Edmonton, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Odongo CN, Dreque CC, Mutiibwa D, Bongomin F, Oyania F, Sikhondze MM, Acan M, Atwine R, Kirya F, Situma M. Etiology, Clinical Presentations, and Short-Term Treatment Outcomes of Extrahepatic Obstructive Jaundice in South-Western Uganda. Clin Exp Gastroenterol 2022; 15:79-90. [PMID: 35721671 PMCID: PMC9199528 DOI: 10.2147/ceg.s356977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background The diagnosis of extrahepatic obstructive jaundice (EHOJ) remains a challenge and is often made late in low-resource settings. Systematic data are limited on the etiology and prognosis of patients with obstructive jaundice in Uganda. The objective of this study was to determine the etiology, clinical presentations, and short-term treatment outcomes of patients managed for EHOJ at Mbarara Regional Referral Hospital (MRRH) in south-western Uganda. Methods Between September 2019 and May 2020, we prospectively enrolled a cohort of patients who presented with EHOJ at MRRH. A pretested, semi-structured data collection tool was used to abstract data from both the study participants and their files. Results A total of 72 patients, 42 (58.3%) of whom were male with a median age of 56 (range of 2 months to 95 years) were studied. Forty-two (58.3%) participants had malignancies: Pancreatic head tumors 20 (27.8%), cholangiocarcinoma 13 (18.1%), duodenal cancers 5 (6.94%), and gall bladder cancer 4 (5.6%). The remaining 30 (41.7%) participants had benign etiologies: choledocholithiasis 10 (13.9%), biliary atresia 7 (9.7%), pancreatic pseudo cyst 6 (8.3%), Mirizzi syndrome 5 (6.9%) and 1 (1.4%) each of chronic pancreatitis and choledochal cyst. Sixty-seven (93.1%) patients presented with right upper quadrant tenderness, 65 (90.3%) abdominal pain and 55 (76.3%) clay-colored stool. Cholecystectomy 11 (25.6%) and cholecystojejunostomy + jejunojejunostomy 8 (18.6%) were the commonest procedures performed. Twelve (17.0%) of cases received chemotherapy (epirubicin/cisplatin/capecitabine) for pancreatic head tumors and (gemcitabine/oxaliplatine) for cholangiocarcinoma. Mortality rate was 29.2% in the study, of which malignancy carried the highest mortality 20 (95.24%). Conclusion Malignancy was the main cause of EHOJ observed in more than half of the patients. Interventions aimed at early recognition and appropriate referral are key in this population to improve outcomes.
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Affiliation(s)
| | | | - David Mutiibwa
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Felix Bongomin
- Department of Microbiology and Immunology, and Internal Medicine, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Felix Oyania
- Department of Surgery, Faculty of Medicine, Kabale University, Kabale, Uganda
| | | | - Moses Acan
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Raymond Atwine
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Kirya
- Department of Anatomy, Faculty of Medicine, Soroti University, Soroti, Uganda
| | - Martin Situma
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Odongo CN, Atwine R, Kirya F, Okello PA, Ogwang E, Acan M, Bongomin F, Situma M. Urinary bladder cavernous hemangioma in a 3‐year‐old: A rare case report. Clin Case Rep 2022; 10:e05875. [PMID: 35600008 PMCID: PMC9109648 DOI: 10.1002/ccr3.5875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/18/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022] Open
Abstract
Cavernous hemangioma (CH) of urinary bladder occurs relatively infrequently, accounting for 0.6% of all bladder tumors. This tumor may occur sporadically or coexist with other benign and malignant vascular lesions. In this report, we present a rare case of CH in a 3‐year‐old Ugandan girl. A 3‐year‐old girl was referred to Mbarara Regional Referral Hospital (MRRH) for urological evaluation following a 3‐year history of intravaginal swelling, dysuria, and heavy hematuria resulting in anemia. Imaging was consistent with polypoid bladder mass arising from the bladder trigone. Embryonal rhabdomyosarcoma was suspected based on clinical eyeballing. She was worked up for chemotherapy and received 26 cycles of vincristine sulfate, actinomycin‐d, and cyclophosphamide (VAC). Biopsy and fulguration were performed after optimizing the patient. Histopathology confirmed CH. The surgery was uneventful and resulted in complete cure. CH should be considered in the differential diagnosis of childhood genitourinary masses. It is a rare entity in the real‐life clinical practice and therefore can be overlooked. Excision biopsy and histology should be performed before initiating the patients to chemotherapy. CH is very insensitive to chemotherapy and therefore surgery maybe adequate in resource‐limited settings.
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Affiliation(s)
| | - Raymond Atwine
- Faculty of Medicine Mbarara University of Science and Technology Mbarara Uganda
| | - Fred Kirya
- Faculty of Medicine Soroti University Soroti Uganda
| | | | - Eugene Ogwang
- Faculty of Medicine Mbarara University of Science and Technology Mbarara Uganda
| | - Moses Acan
- Faculty of Medicine Mbarara University of Science and Technology Mbarara Uganda
| | - Felix Bongomin
- Departments of Medical Microbiology & Immunology, and Internal Medicine Faculty of Medicine Gulu University Gulu Uganda
| | - Martin Situma
- Faculty of Medicine Mbarara University of Science and Technology Mbarara Uganda
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Odongo CN, Dreque CC, Bongomin F, Oyania F, Situma M, Atwine R. Adenomatous Hyperplasia of the Gallbladder in the Setting of Mirizzi Syndrome, Mimicking Adenocarcinoma of the Gallbladder. Int Med Case Rep J 2021; 14:637-641. [PMID: 34584463 PMCID: PMC8464327 DOI: 10.2147/imcrj.s326857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022] Open
Abstract
Background Adenomatous hyperplasia (AH) is an uncommon benign lesion of the gallbladder (GB), predominantly seen in men. AH is commonly confused with malignant GB neoplasms in the setting of chronic cholecystitis and gallstones. There is a scarcity of published literature on AH, suggesting its rarity and the need for this case report. Case Presentation A 24-year-old woman from Western Uganda presented with signs and symptoms consistent with extrahepatic biliary obstruction. Trans-abdominal ultrasound scan revealed cholecystomegaly (13.9 cm by 4.29 cm), thickened GB wall at 5.2 mm, with a poorly defined hypoechoic polypoid solid mass involving the fundal body of the GB. Explorative laparotomy with cholecystectomy and lymph node sampling was performed. Histopathological examination was consistent with adenomatous hyperplasia of the GB. The symptoms and laboratory values improved on follow-up in the clinic after laparotomy. Conclusion Adenomatous hyperplasia may be misdiagnosed as a malignant GB neoplasm, especially in the setting of chronic cholecystitis and gallstones. If a correct histopathological diagnosis is made, no further diagnostic work-up is necessary following surgical interventions.
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Affiliation(s)
- Charles Newton Odongo
- Department of Surgery, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carlos Cabrera Dreque
- Department of Surgery, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Felix Bongomin
- Departments of Medical Microbiology & Immunology, and Internal Medicine, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Felix Oyania
- Department of Surgery, Faculty of Medicine, Kabale University, Kabale, Uganda
| | - Martin Situma
- Department of Surgery, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Raymond Atwine
- Department of Pathology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Grant CL, Tumuhimbise C, Ninsiima C, Robinson T, Eurich D, Bigam D, Situma M, Saleh A. Improved documentation following the implementation of a trauma registry: A means of sustainability for trauma registries in low- and middle-income countries. Injury 2021; 52:2672-2676. [PMID: 34334209 DOI: 10.1016/j.injury.2021.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/29/2021] [Accepted: 07/20/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma registries in low- and middle-income countries (LMICs) are critical for improving trauma care; however, while some registries have been established in low-income settings, few are sustained due to a lack of sustainable funding. In many LMIC institutions, funding is dependent on documentation of trauma patients, but patient records may be of poor quality, missing, or incomplete. The development of a trauma registry and electronic patient registration system could be used to improve documentation of trauma patients in a low-income setting and lead to increased funding for trauma care. METHODS A retrospective chart review of trauma patients at Mbarara Regional Referral Hospital in Uganda was performed, documenting the monthly admissions from January 2015-July 2016 prior to the establishment of a trauma registry. A trauma registry and electronic patient registration system were established in 2017, and monthly admissions from February 2017-December 2019 were documented. A negative binomial regression analysis was performed comparing the incident rate of admission pre-implementation of the registry compared to post-implementation, adjusting for month and year. Completeness of trauma patient records was also assessed. RESULTS Prior to the implementation of the trauma registry and patient registration system (2015-2016), there was a mean of 5.2 (SD 4.4) trauma records per month identified. Following the implementation of the trauma registry, a mean of 103.4 trauma records per month were documented (SD 32.0) for an increased incident rate ratio of 20.9 (95% CI 15.7-27.6, p<0.001). There was also a significant increase in percentage of documents completed (OR 49.1, CI 12.4-193.7, p<0.001). DISCUSSION Following the implementation of a trauma registry and electronic patient registration system at this low-income country hospital, an increase of 20.9 times completed trauma patient documentation was identified, and completion of the records improved. This more accurate documentation could be used to apply for increased government funding for trauma patients and sustain the trauma registry in the long term and could represent a means of long-term sustainability for other trauma registries in LMICs.
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Affiliation(s)
- Chantalle L Grant
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, Canada, T6G 2B7.
| | - Christine Tumuhimbise
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Consolet Ninsiima
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Tessa Robinson
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 690 Water Street, Simcoe, Ontario, Canada, N3Y 4K1.
| | - Dean Eurich
- School of Public Health, University of Alberta, 2-040F Li Ka Shing Centre For Research, 11203 - 87 Ave NW, Edmonton AB Canada, T6G 2H5.
| | - David Bigam
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, Canada, T6G 2B7.
| | - Martin Situma
- Mbarara Regional Referral Hospital, PO Box 1041, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Health Research Methods, Evidence, & Impact, McMaster University, 690 Water Street, Simcoe, Ontario, Canada, N3Y 4K1.
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Office of Global Surgery, 2D2.23 WMHC, 8440-112 St. NW, Edmonton, Alberta, Canada, T6G 2B7.
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Ullrich S, Kisa P, Ruzgar N, Okello I, Oyania F, Kayima P, Kakembo N, Sekabira J, Situma M, Ozgediz D. Implementation of a contextually appropriate pediatric emergency surgical care course in Uganda. J Pediatr Surg 2021; 56:811-815. [PMID: 33183745 DOI: 10.1016/j.jpedsurg.2020.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Low- and middle-income countries like Uganda face a severe shortage of pediatric surgeons. Most children with a surgical emergency are treated by nonspecialist rural providers. We describe the design and implementation of a locally driven, pilot pediatric emergency surgical care course to strengthen skills of these providers. This is the first description of such a course in the current literature. METHODS The course was delivered three times from 2018 to 2019. Modules include perioperative management, neonatal emergencies, intestinal emergencies, and trauma. A baseline needs assessment survey was administered. Participants in the second and third courses also took pre and postcourse knowledge-based tests. RESULTS Forty-five providers representing multiple cadres participated. Participants most commonly perform hernia/hydrocele repair (17% adjusted rating) in their current practice and are least comfortable managing cleft lip and palate (mean Likert score 1.4 ± 0.9). Equipment shortage was identified as the most significant challenge to delivering pediatric surgical care (24%). Scores on the knowledge tests improved significantly from pre- (55.4% ± 22.4%) to postcourse (71.9% ± 14.0%, p < 0.0001). CONCLUSION Nonspecialist clinicians are essential to the pediatric surgical workforce in LMICs. Short, targeted training courses can increase provider knowledge about the management of surgical emergencies. The course has spurred local surgical outreach initiatives. Further implementation studies are needed to evaluate the impact of the training. LEVEL OF EVIDENCE V.
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Affiliation(s)
| | - Phyllis Kisa
- Mulago National Referral Hospital, Kampala, Uganda
| | - Nensi Ruzgar
- Yale University School of Medicine, New Haven, CT
| | | | - Felix Oyania
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | | | | | | | - Doruk Ozgediz
- University of California San Francisco, San Francisco, CA
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20
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Oyania F, Kotagal M, Situma M. 15-Year-old with neglected recto-vestibular fistula in western Uganda: a case report. J Med Case Rep 2021; 15:96. [PMID: 33632306 PMCID: PMC7908786 DOI: 10.1186/s13256-021-02717-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 11/14/2022] Open
Abstract
Background Teenage and late presentation of anorectal malformations are not uncommon in developing world. Some of the reasons for late presentation include but not limited to illiteracy, poverty, lack of awareness, and limited trained pediatric surgeons. In rural areas, neonates with ARMs are considered cursed and are marginalized. Case 15-Year-old African girl (a munyankole by tribe in Uganda) from western Uganda presented at 15 years of life with colostomy and uncorrected anorectal malformation. Never went to school due to social stigma. Conclusion Due to limited number of trained pediatric surgeons in most of African Countries, many children in addition to living with a colostomy or untreated malformation, may also be undiagnosed with chronic constipation. Improved awareness and advocacy would promote early presentation and treatment.
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Affiliation(s)
- Felix Oyania
- Department of Surgery, Pediatric Surgical Unit, Mbarara University of Science and Technology, Mbarara, Uganda. .,Department of Surgery, Kabale University School of Medicine, Kabale, Uganda.
| | - Meera Kotagal
- Cincinnati Children's Medical Centre, Cincinnati, USA
| | - Martin Situma
- Department of Surgery, Pediatric Surgical Unit, Mbarara University of Science and Technology, Mbarara, Uganda
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Commander SJ, Ellis D, Williamson H, Oyania F, Ruhigwa C, Situma M, Fitzgerald TN. Social and financial barriers may contribute to a "hidden mortality" in Uganda for children with congenital anomalies. Surgery 2020; 169:311-317. [PMID: 33097243 DOI: 10.1016/j.surg.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The true incidence of congenital anomalies in sub-Saharan Africa is unknown. Owing to complex challenges associated with congenital anomalies, many affected babies may never present to a health facility, resulting in an underestimation of disease burden. METHODS Interviews were conducted with Ugandans between September 2018 and May 2019. Responses from community members versus families of children with congenital anomalies were compared. RESULTS A total of 198 Ugandans were interviewed (91 family members, 80 community members). All participants (N = 198) believed that seeking surgical care would lead to poverty, 43% (n = 84) assumed fathers would abandon the child, and 26% (n = 45) thought a child with a congenital anomaly in their community had been left to die. Causes of anomalies were believed to be contraceptive methods (48%, n = 95), witchcraft (17%, n = 34), or drugs (10%, n = 19). Of family members, 25 (28%) were advised to allow the child to die. Families with affected children were more likely to have a lower income (P < .001), believe anomalies could be treated (P = .007), but thought that allowing the child to die was best for the family (32% vs 9%; P < .0001). Monthly household income <50,000 Uganda shillings ($13 United States dollars) was a significant predictor of the father leaving the family (P = .024), being advised to not pursue medical care (P = .046), and believing that God should decide the child's fate (P = .047). CONCLUSION Families face significant financial and social pressures when deciding to seek surgical care for a child with a congenital anomaly. Many children with anomalies may die and never reach a health facility to be counted, thus contributing to a hidden mortality.
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Affiliation(s)
| | - Danielle Ellis
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Felix Oyania
- Department of Pediatric Surgery, Mbarara National Referral Hospital, Uganda
| | - Comfart Ruhigwa
- Department of Pediatric Surgery, Mbarara National Referral Hospital, Uganda
| | - Martin Situma
- Department of Pediatric Surgery, Mbarara National Referral Hospital, Uganda
| | - Tamara N Fitzgerald
- Department Surgery, Duke University, Durham, NC; Duke Global Health Institute, Durham, NC.
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Kakembo N, Situma M, Williamson H, Kisa P, Kamya M, Ozgediz D, Sekabira J, Fitzgerald TN. Ugandan Medical Student Career Choices Relate to Foreign Funding Priorities. World J Surg 2020; 44:3975-3985. [PMID: 32951061 DOI: 10.1007/s00268-020-05756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The surgical workforce in sub-Saharan Africa is insufficient to meet population needs. Therefore, medical students should be encouraged to pursue surgical careers and "brain drain" must be minimized. It is unknown to what extent foreign aid priorities influence medical student career choices in Uganda. METHODS Medical students in Uganda completed an online survey examining their career choices and attitudes regarding career opportunities and funding priorities. Data were analyzed using descriptive statistics, and responses among men and women were compared using Fisher's exact tests. RESULTS Ninety-eight students participated. Students were most influenced by inspiring role models, employment opportunities and specialty fit with personal skills. Filling an underserved specialty was near the bottom of the influence scale. Women placed higher importance on advice from mentors (p = 0.049) and specialties with lower stress burden (p = 0.027). Men placed importance on opportunities in non-governmental organizations (p = 0.033) and academia (p = 0.050). Students expressed that the most supported specialties were infectious disease (n = 65, 66%), obstetrics (n = 15, 15%) and pediatrics (n = 7, 7%). Most students (n = 91, 93%) were planning a career in infectious disease. Fifty-three students (70%) indicated plans to leave Africa for residency. Female students were more likely to have a plan to leave (p = 0.027). CONCLUSION Medical students in Uganda acknowledge the career opportunities for physicians in specialties prioritized by the Sustainable Development Goals. In order to avoid "brain drain" and encourage students to pursue careers in surgery, career opportunities including surgical residencies must be prioritized and supported in sub-Saharan Africa.
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Affiliation(s)
- Nasser Kakembo
- Department of Pediatric Surgery, Makerere University, Kampala, Uganda
| | - Martin Situma
- Department of Pediatric Surgery, Mbarara University, Mbarara, Uganda
| | - Hannah Williamson
- Duke Cancer Institute Biostatistics Shared Resource, Durham, NC, USA
| | - Phyllis Kisa
- Department of Pediatric Surgery, Makerere University, Kampala, Uganda
| | - Moses Kamya
- School of Medicine, Makerere University, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University California San Francisco, San Francisco, CA, USA
| | - John Sekabira
- Pediatric Surgery Unit, Mulago Hospital, Kampala, Uganda
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, DUMC, Box 3815, Durham, NC, 27710, USA. .,Duke Global Health Institute, Durham, NC, USA.
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Kisa P, Grabski DF, Ozgediz D, Ajiko M, Aspide R, Baird R, Barker G, Birabwa-Male D, Blair G, Cameron B, Cheung M, Cigliano B, Cunningham D, D'Agostino S, Duffy D, Evans F, Fitzgerald TN, Galiwango G, Gerolmini D, Gerolmini M, Kakembo N, Kambugu JB, Lakhoo K, Langer M, Muhumuza MF, Muzira A, Nabukenya MT, Naik-Mathuria B, Nakku D, Nankunda J, Ogwang M, Okello I, Penny N, Reimer E, Sabatini C, Sekabira J, Situma M, Ssenyonga P, Tumukunde J, Villalona G. Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda. World J Surg 2019; 43:1435-1449. [PMID: 30617561 DOI: 10.1007/s00268-018-04905-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. METHODS The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. RESULTS The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. CONCLUSION Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.
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Affiliation(s)
- Phyllis Kisa
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, USA
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, New Haven, USA.
| | | | | | - Robert Baird
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Gillian Barker
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Doreen Birabwa-Male
- Mulago National Referral Hospital, Uganda Ministry of Health, Kampala, Uganda
| | - Geoffrey Blair
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Brian Cameron
- Department of Surgery, McMaster University Faculty of Health Sciences, Hamilton, Canada
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, USA
| | | | | | | | - Damian Duffy
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Faye Evans
- Department of Anesthesiology, Harvard Medical School, Boston, USA
| | | | | | | | | | - Nasser Kakembo
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | | | - Kokila Lakhoo
- Department of Paediatric Surgery, Oxford University, Oxford, UK
| | - Monica Langer
- Department of Surgery, Northwestern University School of Medicine, Chicago, USA
| | | | - Arlene Muzira
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Mary T Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | | | - Doreen Nakku
- Department of Surgery, Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | - Jolly Nankunda
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
| | | | - Innocent Okello
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Norgrove Penny
- Department of Orthopedics, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Eleanor Reimer
- Department of Anesthesiology, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Coleen Sabatini
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, USA
| | - John Sekabira
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | | | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Gustavo Villalona
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, USA
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Ullrich SJ, Kakembo N, Grabski DF, Cheung M, Kisa P, Nabukenya M, Tumukunde J, Fitzgerald TN, Langer M, Situma M, Sekabira J, Ozgediz D. Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study. J Surg Res 2019; 246:93-99. [PMID: 31562991 DOI: 10.1016/j.jss.2019.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/25/2019] [Accepted: 08/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda. METHODS A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach. RESULTS For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system. CONCLUSIONS Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.
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Affiliation(s)
- Sarah J Ullrich
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - 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
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesiology, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesiology, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Monica Langer
- Department of Surgery, Lurie Children's Hospital, Chicago, Illinois
| | - Martin Situma
- Department of Surgery, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - John Sekabira
- Department of Surgery, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Kayima P, Kitya D, Punchak M, Anderson GA, Situma M. Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda. J Pediatr Surg 2019; 54:838-844. [PMID: 30153942 DOI: 10.1016/j.jpedsurg.2018.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND/PURPOSE Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition. METHODS This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016. RESULTS 78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%. CONCLUSION The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter Kayima
- Department of Surgery, St Mary's Hospital Lacor, Gulu University Medical School, Gulu, Uganda
| | - David Kitya
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Maria Punchak
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
| | - Geoffrey A Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
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MacKinnon N, St-Louis E, Yousef Y, Situma M, Poenaru D. Out-of-Pocket and Catastrophic Expenses Incurred by Seeking Pediatric and Adult Surgical Care at a Public, Tertiary Care Centre in Uganda. World J Surg 2018; 42:3520-3527. [PMID: 29858920 DOI: 10.1007/s00268-018-4691-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Surgical care is critical to establish effective healthcare systems in low- and middle-income countries, yet the unmet need for surgical conditions is as high as 65% in Ugandan children. Financial burden and geographical distance are common barriers to help-seeking in adult populations and are unmeasured in the pediatric population. We thus measured out-of-pocket (OOP) expenses and distance traveled for pediatric surgical care in a tertiary hospital in Mbarara, Uganda, as compared to adult surgical and pediatric medical patients. METHODS Patients admitted to pediatric surgical (n = 20), pediatric medical (n = 18) and adult surgical (n = 18) wards were interviewed upon discharge over a period of 3 weeks. Patient and caregiver-reported expenses incurred for the present illness included prior/future care needed, and travel distance/cost. The prevalence of catastrophic expenses (≥10% of annual income) was calculated and spending patterns compared between wards. RESULTS Thirty-five percent of pediatric medical patients, 45% of pediatric surgical patients and 55% of adult surgical patients incurred catastrophic expenses. Pediatric surgical patients paid more for their current treatment (p < 0.01)-specifically medications (p < 0.01) and tests (p < 0.01)-than pediatric medical patients, and comparable costs to adults. Adult patients paid more for treatment prior to the hospital (p = 0.04) and miscellaneous expenses (e.g., food while admitted) (p = 0.02). Patients in all wards traveled comparable distances. CONCLUSIONS Seeking healthcare at a publicly funded hospital is financially catastrophic for almost half of patients. Out-of-stock supplies and broken equipment make surgical care particularly vulnerable to OOP expenses because analgesics, anaesthesia and preoperative imaging are prerequisites to care.
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Affiliation(s)
| | - Etienne St-Louis
- Center for Global Surgery, McGill University Health Centre, Montreal, Canada
| | - Yasmine Yousef
- Center for Global Surgery, McGill University Health Centre, Montreal, Canada
| | | | - Dan Poenaru
- Center for Global Surgery, McGill University Health Centre, Montreal, Canada.
- Montreal Children's Hospital, Rm. B- 04.2022, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada.
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Pilkington M, Situma M, Winthrop A, Poenaru D. Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara Regional Referral Hospital, Uganda. J Pediatr Surg 2018; 53:1073-1079. [PMID: 29548493 DOI: 10.1016/j.jpedsurg.2018.02.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/01/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Favorable surgical outcomes depend on timely access to care. This study quantifies these delays and explores caregiver barriers to access in a Ugandan facility. METHODS An interviewer-facilitated survey was administered over 8months to consecutive pediatric surgical families at Mbarara Regional Referral Hospital (MRRH). Delays were classified using the Three Delays Model: care-seeking, arrival at health facility, and from surgical consultation to surgery. Barriers at each stage were explored with caregivers. RESULTS The survey included 174 patients. Family members were first to recognize disease in 90%, but only 14% sought medical attention immediately. Delays in seeking care predominated (median 30days), mostly attributed to home treatments (51%) and other responsibilities (28%). After referral decision, 80% of caregivers brought their child to MRRH immediately (median time to arrival <24h). Upon MRRH arrival, 57% of patients were assessed the same day, and time to surgery was relatively short (median 4days). Despite free under-5 care, out-of-pocket payments (between $1-42 USD) were reported by 64%. CONCLUSIONS Care-seeking delays dominate access to pediatric surgical care in Uganda, and cost remains a significant barrier. Primary provider education and advocacy for increased resources would be useful interventions to improve timeliness of pediatric surgical care. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - Martin Situma
- Mbarara University Teaching Hospital, Mbarara University for Science and Technology, Mbarara, Uganda
| | - Andrea Winthrop
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Dan Poenaru
- Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Liu C, Kayima P, Riesel J, Situma M, Chang D, Firth P. Brief surgical procedure code lists for outcomes measurement and quality improvement in resource-limited settings. Surgery 2017; 162:1163-1176. [PMID: 28864101 DOI: 10.1016/j.surg.2017.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/23/2017] [Accepted: 07/04/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lack of a classification system for surgical procedures in resource-limited settings hinders outcomes measurement and reporting. Existing procedure coding systems are prohibitively large and expensive to implement. We describe the creation and prospective validation of 3 brief procedure code lists applicable in low-resource settings, based on analysis of surgical procedures performed at Mbarara Regional Referral Hospital, Uganda's second largest public hospital. METHODS We reviewed operating room logbooks to identify all surgical operations performed at Mbarara Regional Referral Hospital during 2014. Based on the documented indication for surgery and procedure(s) performed, we assigned each operation up to 4 procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification. Coding of procedures was performed by 2 investigators, and a random 20% of procedures were coded by both investigators. These codes were aggregated to generate procedure code lists. RESULTS During 2014, 6,464 surgical procedures were performed at Mbarara Regional Referral Hospital, to which we assigned 435 unique procedure codes. Substantial inter-rater reliability was achieved (κ = 0.7037). The 111 most common procedure codes accounted for 90% of all codes assigned, 180 accounted for 95%, and 278 accounted for 98%. We considered these sets of codes as 3 procedure code lists. In a prospective validation, we found that these lists described 83.2%, 89.2%, and 92.6% of surgical procedures performed at Mbarara Regional Referral Hospital during August to September of 2015, respectively. CONCLUSION Empirically generated brief procedure code lists based on International Classification of Diseases, 9th Revision, Clinical Modification can be used to classify almost all surgical procedures performed at a Ugandan referral hospital. Such a standardized procedure coding system may enable better surgical data collection for administration, research, and quality improvement in resource-limited settings.
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Affiliation(s)
- Charles Liu
- Stanford University Medical Center, Stanford, CA.
| | - Peter Kayima
- Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Johanna Riesel
- Harvard Combined Plastic Surgery Residency, Brigham and Women's Hospital, Boston, MA
| | - Martin Situma
- Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | | | - Paul Firth
- Massachusetts General Hospital, Boston, MA
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Tungotyo M, Atwine D, Nanjebe D, Hodges A, Situma M. The prevalence and factors associated with malnutrition among infants with cleft palate and/or lip at a hospital in Uganda: a cross-sectional study. BMC Pediatr 2017; 17:17. [PMID: 28086763 PMCID: PMC5237292 DOI: 10.1186/s12887-016-0775-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 12/30/2016] [Indexed: 11/28/2022] Open
Abstract
Background To determine the prevalence and factors associated with malnutrition among infants with Cleft palate and/or cleft lip (CP+/-L) at Comprehensive Rehabilitation for Uganda Hospital (CoRSU) in Uganda. Methods This was a cross-sectional study done on infants with CP+/-L and their caretakers admitted between November 2013 and October 2014 at CoRSU hospital which was the study setting. A questionnaire was answered by the infants’ caretakers. The main outcome measure, malnutrition was defined and classified based on Z-scores obtained using the W.H.O Z-calculator in which weights of the infants in kilograms and lengths in centimeters respectively were placed. The values obtained were expressed as a proportion using all enrolled infants with CP+/-L as denominator. Multivariable analysis was used to determine the risk factors. Results A total of 44 infants with CP+/-L were enrolled. Of these, 77% were below 4 months of age and 97.7% were immunized. The male-to-female ratio was 1.06:1. About 59% had unilateral CP+/-L. A total of 93.2% were delivered at term with 69.4% having a birth weight greater than 3 kg. Generally, 68% were malnourished, with the highest burden among females (71.4%), infants below 4 months (73.5%) and those with unilateral CP+/-L (77%). About 57% had moderate-to-severe malnutrition. There was delayed supplementation to breast milk, with cow-milk as the main supplemental feed for all the infants. In the multivariable analysis, factors associated with malnutrition included, having caretakers lacking nutritional information post-delivery (OR = 3.8, p = 0.17), low birth weight (OR = 3.4, p = 0.20), and having less than 10 feeds/day (OR = 4.9, p = 0.09). Conclusion CP+/-L infants born in Uganda suffer a high-burden of malnutrition. Preventional strategies are needed with focus on proper feeding information. Research on cost-effective feeds, feeding methods and reasons behind gender disparities in these infants is also required.
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Affiliation(s)
- Martin Tungotyo
- Mbarara University of Science and Technology (M.U.S.T), Mbarara, Uganda.
| | - Daniel Atwine
- Mbarara University of Science and Technology (M.U.S.T), Mbarara, Uganda
| | - Deborah Nanjebe
- Mbarara University of Science and Technology (M.U.S.T), Mbarara, Uganda
| | - Andrew Hodges
- Comprehensive Rehabilitation Services for Uganda (CoRSU) Hospital, Kisubi, Uganda
| | - Martin Situma
- Mbarara University of Science and Technology (M.U.S.T), Mbarara, Uganda
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Situma M, Alexander A, Weiselthaler N, Millar A. An aggressive lymphatic malformation (Gorham's disease) leading to death of a child. J Pediatr Surg 2013; 48:239-42. [PMID: 23331822 DOI: 10.1016/j.jpedsurg.2012.10.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 10/15/2012] [Accepted: 10/16/2012] [Indexed: 01/09/2023]
Abstract
Here in, we present a case of aggressive Gorham's disease in a 10 year old boy. We document its evolution from a seemingly benign buttock mass to a widely invasive disease that was ultimately fatal. We highlight the challenges in the management of such an aggressive, yet benign process and review the available literature on the subject.
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Affiliation(s)
- Martin Situma
- Department of Paediatric Surgery, The Red Cross War Memorial Children's Hospital, Claremont 7700, Cape Town, South Africa
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