The importance of global bioethics to paediatric health care

The paradigm of values adopted by the global health community has a palpable, albeit often unseen, impact on patient health care. In this Viewpoint, we investigate an inherent tension in the core values of medical ethics and clinical practice that could explain why paediatric health care faces resource constraints despite compelling economic and societal imperatives to prioritise child health and wellbeing. The dominant narrative in the philosophy of medicine tends to disproportionately underscore values of independence and self-determination, which becomes problematic in the context of paediatric patients, who by their very nature epitomise vulnerability and dependence. A double-jeopardy situation arises when disadvantaged children see their inherent dependence leveraged against them. We illustrate this predicament through specific examples relating to rights and obligations and to autonomy. Alternative value perspectives-communitarianism and relational autonomy-might offer more robust protection for vulnerable children. A shift away from the dominant narrative towards a more explicit and inclusive discussion of values is necessary. Such a shift requires giving a legitimate platform to diverse perspectives, with the presumption that collective moral progress is possible; this endeavour is embodied by global bioethics. Successful implementation of global bioethics, in turn, hinges on close collaboration between practicing clinicians and bioethicists. Taking global bioethics seriously and actively pursuing collaboration could help the global health community achieve more equitable health care.

Proper ophthalmic artery aneurysms

Background

The ophthalmic segment of the internal carotid artery (ICA) represents a common site for cerebral aneurysms. However, aneurysms of the ophthalmic artery (OphA) itself represent rare lesions and have been associated with trauma and flow-related lesions such as arteriovenous fistulas or malformations. Here, we explore clinical and radiological features of four patients managed for five proper ophthalmic artery aneurysms (POAAs).

Methods

Patients undergoing diagnostic cerebral angiogram (DCA) between January 2018 and November 2021 with newly or previously identified POAA were retrospectively reviewed. Clinical and radiological data were analyzed to identify common and unique features.

Results

Four patients with identification of five POAA were identified. Three patients suffered traumatic brain injury with subsequent identification of POAA on DCA. Patient 1 presented with a traumatic carotid-cavernous-sinus fistula requiring transvenous coil embolization and second stage flow diversion of the ICA. Patient 2 suffered a gunshot wound with ICA compromise, ethmoidal dural arteriovenous fistula (dAVF) development with rapid growth of two POAAs eventually requiring Onyx embolization. Patient 3 was assaulted and DCA showed a POAA without any other cerebrovascular pathology. Patient 4 had undergone N-butyl cyanoacrylate embolization of an ethmoidal dAVF 13 years ago with the feeding OphA carrying a large POAA. Re-DCADCA was performed for a newly developed and unrelated transverse-sigmoid-sinus dAVF.

Conclusion

Management of POAAs poses a challenge to neurovascular surgeons since POAAs inherit a risk for visual deterioration or hemorrhage. DCA facilitates identification of coexisting cerebrovascular pathology. If clinically silent and not accompanied by cerebrovascular disease, observation appears reasonable.

59 Burns in Low- and Middle-income Countries: A Scientometric Analysis of Peer-reviewed Research

Introduction

Low- and middle-income countries (LMICs) account for 70% of all global burns. Due to this significantly disproportionate burden, it’s critical we identify barriers to burn care and prevention in LMICs. As a result, this study aimed to elucidate trends in LMIC-related burn research to create focused strategies for burn care training, research, and innovation. Accomplishing meaningful change from the study’s findings will be guided by the first 4 steps of Dr. John Kotter’s “8-Step Process for Leading Change” – 1) create urgency for change, 2) build a guiding team, 3) develop a vision and plan, 4) communicate with key stakeholders to obtain buy-in.

Methods

Web of Science’s 7 citation databases were searched through March 2, 2021 using synonyms of “burns” and “low- and middle-income countries.” After screening articles, metadata were uploaded to VOSviewer (Leiden, Netherlands) where citation and network metrics were generated. The Kruskal-Wallis test and linear regression were used for bivariable and multivariable analysis of factors influencing publications, citations, and total link strength (TLS) – the strength of association between a given research article, other articles, and additional institutions.

Results

Bibliometric analysis identified 2,027 articles by 8,602 authors in 692 journals. Two-thirds of journals published a single article (n=453, 65.5%) whereas only 3.6% published ≥10 articles. One-quarter of LMIC burn research was published in ISBI’s Burns (n=417 articles, 20.6%) and ABA’s Journal of Burn Care & Research (n=89 articles, 4.4%). Most authors published < 5 articles (n=8521, 99.1%) but 19 (0.2%) had published ≥10. Authors were affiliated with 2,519 organizations in 132 countries. There was a strong positive correlation between total publications and citations (R=0.87, P< 0.001). In addition, there was a significant difference in the number of publications (P=0.003, 0.07), citations (P=0.005, 0.03), and TLS (P=0.009, 0.008) by geographic and economic categories - North America had the highest while Latin American and the Caribbean had the lowest. The USA (n = 563), India (n = 161), and China (n = 154) published the most articles.

Conclusions

Given the disproportionate representation of high-income countries and authors in the current LMIC burn research landscape, there must be a sense of urgency to develop pathways for facilitating change. Local and regional candidates for mentors and leaders were identified using bibliometric findings. Assembling teams with these individuals and prolific authors using a well-defined vision for change will facilitate sustainable communication and collaboration within LMIC research.

Should intravenous acetaminophen be considered for post craniotomy pain management? A Meta-analysis of randomized controlled trials

INTRODUCTION

Post craniotomy pain management with opioids is challenging due to their side effects, which might mask neurological deterioration symptoms. Recently, intravenous (IV) acetaminophen has been tested in this population. This meta-analysis aimed to synthesize evidence from published randomized controlled trials (RCTs) about the efficacy of IV acetaminophen in reducing pain scores in postoperative craniotomy patients.

EVIDENCE ACQUISITION

A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. We selected RCTs comparing IV acetaminophen versus placebo for postoperative pain management in craniotomy patients. Data on the visual analog scale (VAS), opioid requirements, hospital stay, and patients' satisfaction weexretr acted and pooled as standardized mean difference (SMD) with the corresponding 95% confidence intervals (CI) in the meta-analysis model.

EVIDENCE SYNTHESIS

Five RCTs, with a total of 493 patients, were pooled in the final analysis. Patients in the IV acetaminophen group had significantly lower VAS pain scores compared to the placebo group (SMD -0.28, 95% CI [-0.46 to -0.10]). However, in terms of opioid requirement, hospital stay, and patients' satisfaction, there were no statistically significant differences between both groups (P>0.05).

CONCLUSIONS

This meta-analysis provides class one evidence that IV Acetaminophen can significantly reduce postoperative pain in craniotomy patients with an excellent safety profile; however, there are not benefits in terms of hospital stay, opioid requirement, or patients' satisfaction.

Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review

Background

Low- and middle-income countries (LMICs) bear the majority of the neurosurgical burden of diseases but lack the resources to meet these needs.

Objective

As we increase access to neurosurgical care in LMICs, we must understand patient attitudes toward neurosurgery.

Methods and Material

PubMed, LILACS, and African Journals Online databases were searched systematically from inception to January 4, 2020, for studies on neurosurgical patient perceptions in LMICs. The articles found were blindly reviewed with Rayyan by two authors. The two authors resolved conflicts between themselves, and when this was not possible, a third reviewer was consulted. All the articles included were then appraised, and the results were summarized.

Results

Six of the 1,175 articles met the inclusion criteria. The studies were set in Brazil, Ethiopia, India, Nigeria, South Korea, and Sub-Saharan Africa. Four of the studies (50%) were phenomenological studies, and the other two were grounded theory and narrative. The studies identified patient attitudes toward neurosurgical practitioners, diseases, and interventions. Ethiopian and Nigerian patients believed cranial diseases to be otherworldly and resorted to traditional medicine or spiritual healing first, whereas Brazilian patients were more comfortable with cranial diseases and even more so if they had had a previous craniotomy. The Indian paper was a recount of a neurosurgeon's experience as a spine patient.

Conclusions

There are few studies on neurosurgery patient perception in LMICs. LMIC neurosurgeons should be encouraged to study their patient beliefs concerning neurosurgical diseases and interventions, as this can explain health-seeking behaviors.

Needs of Young African Neurosurgeons and Residents: A Cross-Sectional Study

Introduction: Africa has many untreated neurosurgical cases due to limited access to safe, affordable, and timely care. In this study, we surveyed young African neurosurgeons and trainees to identify challenges to training and practice.

Methods: African trainees and residents were surveyed online by the Young Neurosurgeons Forum from April 25th to November 30th, 2018. The survey link was distributed via social media platforms and through professional society mailing lists. Univariate and bivariate data analyses were run and a P-value < 0.05 was considered to be statistically significant.

Results: 112 respondents from 20 countries participated in this study. 98 (87.5%) were male, 63 (56.3%) were from sub-Saharan Africa, and 52 (46.4%) were residents. 39 (34.8%) had regular journal club sessions at their hospital, 100 (89.3%) did not have access to cadaver dissection labs, and 62 (55.4%) had never attended a WFNS-endorsed conference. 67.0% of respondents reported limited research opportunities and 58.9% reported limited education opportunities. Lack of mentorship (P = 0.023, Phi = 0.26), lack of access to journals (P = 0.002, Phi = 0.332), and limited access to conferences (P = 0.019, Phi = 0.369) were associated with the country income category.

Conclusion: This survey identified barriers to education, research, and practice among African trainees and young neurosurgeons. The findings of this study should inform future initiatives aimed at reducing the barriers faced by this group.

P68 International Survey Of Medical students Exposure to Relevant global Surgery (ISOMERS): A cross-sectional study

Introduction

Medical students around the world have been showing an increasing interest in Global Surgery as evident by their participation in various organizations on local and international levels. We set out to evaluate exposure of medical students to global surgery, modes of exposure, whether the exposure meets the needs of students, awareness of the key messages of the Lancet Commission on Global Surgery, global surgery career aspirations and barriers to said aspirations.

Methods

We developed the International Survey Of Medical students Exposure to Relevant global Surgery (ISOMERS) study, an online, international, questionnaire-based study. This survey will collect data from final year medical students across the world. The questionnaire utilises a combination of the Likert scale, multiple choice options and free text questions and will be disseminated by email and social media through the International Student Surgical Network, a global surgery student interest group with more than 5,000 members.

Results

Primary outcomes will include exposure to global surgery research, advocacy and education among medical students. We will generate simple descriptive statistics and identify determinants of exposure among medical students and subgroups (country income class and geographic region). Also, we will use multinomial regression analysis to identify confounders and significant dependent variables.

Conclusion

The ISOMERS study will identify the level of exposure to global surgery among students during medical education. An understanding of this exposure will be crucial in developing the foundation for global surgery education at the level of undergraduate medical curriculum and furthered in addressing perceived barriers to joining the global surgery workforce.

V11 The trends of the indications and outcomes of cesarean section in Bukavu - A single-center cross-sectional study

Introduction

Cesarean sections (CS) can avert maternal and fetal death and disability. The CS rate varies considerably around the world. While in underserved regions, CS rates are low, in higher income settings, there appears to be too many CS. The objective of this study was to describe the temporal evolution of the indications, practice, and outcomes of CS in Bukavu, Democratic Republic of Congo.

Methods

This cross-sectional study was conducted using the hospital records of women who delivered by CS from January 01, 2014, to December 31, 2017, at the University clinics of Bukavu. Summary descriptive, bivariate, and regression analyses were conducted. The threshold of significance of the alpha was set at 0.05.

Results

Out of the 3,772 women who gave birth, 502 delivered by CS (CS rate=13.3%). The mean age of the women was 26.1 ± 6.4 years, mean gravidity was 3.5 ± 3.0, and the mean parity was 3.3 ± 2.7. Both gravidity (p = 0.007) and parity (p = 0.013) were significant variables in the regression model. 98.2% of CS were emergent, and a general practitioner performed 97.6%. Robson group 1 (30.0%), 5 (29.5%), and 3 (27.1%) were the major CS indications. The complication rate was 7.6%. Surgeons registered 29 (5.8%) intraoperative bleeds, 4 (0.8%) bladder injuries, 5 (1.0%) postpartum hemorrhages, 3 (0.6%) functional ileus, 3 (0.6%) superficial surgical site infections, and 7 (1.4%) endometritis.

Conclusion

The frequency of CS is optimal at the University Clinics of Bukavu. Its indications are evolving with time.

Systemic disorders and the prognosis of stroke in Congolese patients: a cross-sectional study

OBJECTIVES

Stroke is one of the leading causes of death, disability, and dementia in developing countries. Our study aimed to evaluate the systemic disorders associated with mortality in patients admitted within 72 hours of the initial stroke event.

SETTING

The study took place at a tertiary hospital in Kinshasa.

PARTICIPANTS

Patients admitted within 72 hours of the initial stroke event.

INTERVENTIONS

This cross-sectional study consisted of a retrospective review of stroke patient records from January 2016 to December 2018. The Pearson-Chi square test and odds ratios were calculated with a threshold of significance of 0.05.

MAIN OUTCOME MEASURES

Mortality.

RESULTS

We recruited 114 cases. The mean age was 61.8 ± 2.4 years, and the sex ratio was 1.78 in favor of men. Hypertension (76.3%), dyslipidemia (71.1%), and diabetes mellitus (58.8%) were the most frequent comorbidities. Most patients had hypoxia (85.9%), hypertension (82.4%), hyperglycemia (57.8%), and fever (28.1%). We registered thirty-two deaths (28.1%): 20 (62.5%) from the ischemic strokes, and 12 (37.5%) from hemorrhagic strokes. Systemic disorders with the worst prognosis during were arterial hypotension (OR=3.87, p >0.001), and fever (OR =1.56, p = 0.047).

CONCLUSION

Arterial hypotension and fever adversely affect stroke patient outcomes, and strokes are responsible for high mortality in Congo.

FUNDING

Not applicable.

Determinants of Residency Program Choice in Two Central African Countries: An Internet Survey of Senior Medical Students

Background: Central African countries have an increasing burden of disease, low specialist workforce densities, and under-resourced postgraduate medical education. The residency program choice of today’s medical students will determine specialist workforce density in the near future. This study aims to elucidate the factors that influence the choice of residency programs among medical students of two Central African countries. Methods: We designed an online questionnaire in French and English with closed-ended, open-ended, and Likert scale questions. Links to both forms were shared via the international messaging application, WhatsApp, and data were collected anonymously for one month. Respondents were sixth- and seventh-year medical students enrolled in nine Cameroonian and Congolese schools. The threshold of significance was set at 0.05 for bivariate analysis. Results: There were 149 respondents in our study, 51.7% were female, and 79.2% were from Cameroon. Almost every student (98%) expressed the wish to specialize, and a majority (77.2%) reported an interest in a residency program abroad. Preferred destinations were France (13.7%), Canada (13.2%), and the U.S.A. (11.9%). The most popular specialties were cardiology (9.4%), pediatrics (9.4%) and obstetrics and gynecology (8.7%). The choice of specialty was made based on the respondent’s perceived skills (85.9%), anticipated pay after residency (79.2%), and patient contact (79.2%). Conclusion: Understanding which specialties interest Cameroonian and Congolese medical students and the reasons for these choices can help develop better local programs.

Diagnosis of Fraser syndrome missed out until the age of six months old in a low-resource setting: a case report

Background

Fraser syndrome is a rare genetic disorder that often presents with ocular, renal, genital and limb’s congenital anomalies. The prognosis of this genetic disorder depends on the severity of the combination of congenital malformations, some of which may be fatal. The diagnosis of Fraser syndrome is based on established clinical criteria and genetic tests. The criteria enabling clinical diagnosis are visible dysmorphic features present at birth, hence, Fraser syndrome can easily diagnosed at birth, except when health professionals are inexperienced in clinical recognition. Herein, we report a case of Fraser syndrome missed out at birth and fortuitously diagnosed at the age of six months in a bid to raise clinicians’ awareness, particularly in resource-limited settings.

Case presentation

We report a case of a six-month-old Cameroonian female infant, born at home and taken the following day to a primary healthcare facility for neonatal care. Her mother had no antenatal care until birth. She presented at our health center with respiratory distress and fever. She had a temperature of 38.8 °C and signs of left lung basal consolidation, suggestive of a left lower lober pneumonia, confirmed on chest x-ray. Other incidental clinical findings were several dysmorphic features like bilateral cryptophthalmos, nasal malformation, anal imperforation (with a perianal fistula), an external genital anomaly and syndactyly characteristic of Fraser syndrome associated with pneumonia. The patient responded well to intravenous antibiotics for the treatment of her pneumonia. Thereafter, she was referred to a pediatric surgeaon for surgical corrections of her bilateral cryptophthalmos, anal imperforation, external genital defect and syndactyly.

Conclusion

Here we presented a case of Fraser syndrome in a Cameroonian infant whose diagnosis was missed out at birth and fortuitously made at six months of age. In view of the serious and potentially fatal complications of this genetic disorder, we draw clinicians’ attention, especially obstetricians, midwives and pediatricians for a high index of clinical suspicion geared at a timely diagnosis and management. Also, for a timely diagnosis, health education on regular antenatal and postnatal follow ups of  the mother-infant couple respectively, cannot be overemphasized.