Publications

Background

International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development.

Methods

In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented.

Results

Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking.

Conclusions

This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Background

Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement.

Methods

Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care.

Results

Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care.

Conclusions

This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.

Purpose

Delaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery.

Design

Retrospective, observational cohort study using 2006-2014 Medicare claims.

Participants

Medicare beneficiaries 66+ years of age with a Current Procedural Terminology claim for ocular biometry.

Methods

We measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting ≥ 30 days or ≥ 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in ≥ 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high-testing physicians.

Main outcome measures

Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior.

Results

Of 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of high-testing physicians waited ≥ 30 days and ≥ 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist ≤ 40 years of age, and low surgical volume.

Conclusions

Overuse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.

Objective

To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective.

Background

Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children.

Methods

In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%.

Findings

In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country’s gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses.

Conclusion

Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.

The burden of unmet surgical need is heavily weighted toward low-income and middle-income countries. North American orthopaedic surgeons are increasingly interested in volunteer activities in resource-limited areas around the globe. There are multiple avenues through which an orthopaedic surgeon can positively contribute to improving musculoskeletal care around the world. Unfortunately, short-term missions are at risk of undermining local long-term development efforts if they do not mitigate harm and optimize benefit for host communities. Work in this area should be grounded in beneficence and sustainability with an emphasis on mutual respect, exchange, and a commitment to capacity building. All of the necessary information for adequate preparation for these activities is beyond the scope of this chapter, but the goal is to introduce a range of volunteer options, ethical considerations, cultural competence and volunteer preparedness principles, considerations when including trainees in global health work, and some nuts-and-bolts details on trip planning.

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.

Background

Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice.

Method

Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater.

Results

Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%).

Conclusions

The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training.

Purpose

The challenges in providing urologic care across borders and in resource-constrained settings are poorly understood. We sought to better characterize the impediments to the delivery of urological care in low- and middle-income countries (LMICs) compared to high-income countries (HICs).

Methods

A 70 question online survey in RedCap™ was distributed to urologists who had practiced in countries outside of the United States and Europe categorized by World Bank income groups.

Results

114 urologists from 27 countries completed the survey; 35 (39%) practiced in HICs while 54 (61%) practiced in LMICs. Forty-three percent of urologists received training outside their home country. Most commonly treated conditions were urolithiasis (30%), BPH (15%) and prostate cancer (13%) which did not vary by group. Only 19% of urologists in LMICs reported sufficient urologists in their country. Patients in LMICs were less likely to get urgent drainage for infected obstructing kidney stones or endoscopic treatment for a painful kidney stone or obstructing prostate. Urologists visiting LMICs were more likely to cite deficits in knowledge, inadequate operative facilities and limited access to disposables as the major challenges whereas local LMIC urologists were more likely to cite financial challenges, limited access to diagnostics and support staff as the barriers to care.

Conclusions

LMICs lack enough training opportunities and urologists to care for their population. There is disconnect between the needs identified by local and visiting urologists. International collaborations should target broader interventions in LMICs to address local priorities such as diagnostic studies, support staff and financial support.

Safe and accessible surgical and anesthetic care is critically limited for over half of the world’s population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.

Background

Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.

Methods

We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.

Results

The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.

Conclusion

Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.

Background

Following early implementation of public health measures, San Francisco has experienced a slow rise and a low peak level of coronavirus disease 2019 (COVID-19) cases and deaths.

Methods and findings

We included all patients with COVID-19 pneumonia admitted to the intensive care unit (ICU) at the safety net hospital for San Francisco through April 8, 2020. Each patient had ≥15 days of follow-up. Among 26 patients, the median age was 54 years (interquartile range, 43 to 62), 65% were men, and 77% were Latinx. Mechanical ventilation was initiated for 11 (42%) patients within 24 hours of ICU admission and 20 patients (77%) overall. The median duration of mechanical ventilation was 13.5 days (interquartile range, 5 to 20). Patients were managed with lung protective ventilation (tidal volume <8 ml/kg of ideal body weight and plateau pressure ≤30 cmH2O on 98% and 78% of ventilator days, respectively). Prone positioning was used for 13 of 20 (65%) ventilated patients for a median of 5 days (interquartile range, 2 to 10). Seventeen (65%) patients were discharged home, 1 (4%) was discharged to nursing home, 3 (12%) were discharged from the ICU, and 2 (8%) remain intubated in the ICU at the time of this report. Three (12%) patients have died.

Conclusions

Good outcomes were achieved in critically ill patients with COVID-19 by using standard therapies for acute respiratory distress syndrome (ARDS) such as lung protective ventilation and prone positioning. Ensuring hospitals can deliver sustained high-quality and evidence-based critical care to patients with ARDS should remain a priority.

Background

Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures.

Methods

Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05).

Results

Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC).

Conclusion

This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings.

Level of evidence

Level II-prospective comparative study.

Objective

North American pediatric surgery training programs vary in exposure to index cases, while controversy exists regarding fellow participation in global surgery rotations. We aimed to compare the case logs of graduating North American pediatric surgery fellows with graduating Ugandan pediatric surgery fellows.

Design

The pediatric surgery training program at a regional Ugandan hospital hosts a collaboration between Ugandan and North American attending pediatric surgeons. Fellow case logs were compared to the Accreditation Council for Graduate Medical Education Pediatric Surgery Case Log 2018 to 19 National Data Report.

Setting

Mulago National Referral Hospital in Kampala, Uganda; and pediatric surgery training programs in the United States and Canada.

Results

Three Ugandan fellows completed training and submitted case logs between 2011 and 2019 with a mean of 782.3 index cases, compared to the mean 753 cases in North America. Ugandan fellows performed more procedures for biliary atresia (6.7 versus 4), Wilm’s tumor (23.7 versus 5.7), anorectal malformation (45 versus 15.7), and inguinal hernia (158.7 versus 76.8). North American fellows performed more central line procedures (73.7 versus 30.7), cholecystectomies (27.3 versus 3), extracorporeal membrane oxygenation cannulations (16 versus 1), and congenital diaphragmatic hernia repairs (16.5 versus 5.3). All cases in Uganda were performed without laparoscopy.

Conclusions

Ugandan fellows have access to many index cases. In contrast, North American trainees have more training in laparoscopy and cases requiring critical care. Properly orchestrated exchange rotations may improve education for all trainees, and subsequently improve patient care.

Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children’s surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children’s surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children’s surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.

Purpose

In high-income countries the presentation and treatment of intussusception is relatively rapid, and most cases are correctable with radiographically-guided reduction. In low-income countries, many delays affect outcomes and surgical intervention is required. This study characterizes the burden and outcome of pediatric intussusception in Uganda.

Methods

Prospective case series of intussusception cases from May 2015 to July 2016 at a tertiary referral hospital in Uganda.

Results

Forty patients were included in the study. Male to female ratio was 3:2. Average duration of symptoms before presentation was 4.5 days. Median duration of symptoms in referred patients was 4 days and 2 days in non-referred patients (P value 0.0009). All 40 patients underwent surgical treatment: 25% had resection and enterostomy, 15% had resection and primary anastomosis, 2.5% had resection, primary anastomosis and enterostomy and 57.5% underwent manual reduction. Mortality was 32% and febrile patients on admission were 20 times more likely to die (P value 0.040).

Conclusion

Intussusception carries a high operative and mortality rate in Uganda. Referred patients presented later than non-referred patients to health facilities. Fever on examination at admission was positively associated with mortality. This disease remains a target for quality metrics in global pediatric surgery.

Type of study

Diagnostic study.

Level of evidence

III.

Background

The significant burden of emergency operations in low- and middle-income countries can overwhelm surgical capacity leading to a backlog of elective surgical cases. The purpose of this investigation was to determine the burden of emergency procedures on pediatric surgical capacity in Uganda and to determine health metrics that capture surgical backlog and effective coverage of children’s surgical disease in low- and middle-income countries.

Methods

We reviewed 2 independent and prospectively collected databases on pediatric surgical admissions at Mulago National Referral Hospital and Mbarara Regional Referral Hospital in Uganda. Pediatric surgical patients admitted at either hospital between October 2015 to June 2017 were included. Our primary outcome was the distribution of surgical acuity and associated mortality.

Results

A combined total of 1,930 patients were treated at the two hospitals, and 1,110 surgical procedures were performed. There were 571 emergency cases (51.6%), 108 urgent cases (9.7%), and 429 elective cases (38.6%). Overall mortality correlated with surgical acuity. Emergency intestinal diversions for colorectal congenital malformations (anorectal malformations and Hirschsprung’s disease) to elective definitive repair was 3:1. Additionally, 30% of inguinal hernias were incarcerated or strangulated at time of repair.

Conclusion

Emergency and urgent operations utilize the majority of operative resources for pediatric surgery groups in low- and middle-income countries, leading to a backlog of complex congenital procedures. We propose the ratio of emergency diversion to elective repair of colorectal congenital malformations and the ratio of emergency to elective repair of inguinal hernias as effective health metrics to track this backlog. Surgical capacity for pediatric conditions should be increased in Uganda to prevent a backlog of elective cases.

Background

The Kampala Advanced Trauma Course (KATC) was developed in 2007 due to a locally identified need for an advanced trauma training curriculum for the resource-constrained setting. We describe the design, implementation and evaluation of the course.

Methods

The course has been delivered to over 1,000 interns rotating through surgery at Mulago National Referral Hospital. Participants from 2013 to 2016 were surveyed after completion of the course.

Results

The KATC was developed with local faculty and includes didactic and simulation modules. Over 50% of survey respondents reported feeling confident performing and teaching 7 of 11 course skills and felt the most relevant skill was airway management(30.2%). Participants felt least confident managing head trauma(26.4%). Lack of equipment(52.8%) was identified as the most common barrier to providing trauma care.

Conclusions

Providers are confident with most skill sets after taking the KATC. Minimal dependence on instructors from high-income countries has kept the course sustainable and maximized local relevance.

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.

Article 25 of the United Nations’ Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.

The increasing focus on and importance of surgical care in achieving universal health coverage requires the development of safe and accessible anaesthesia services. Increasing access to care by supporting the necessary inputs to the anaesthesia system, including medications, equipment and personnel, must be accompanied by processes that support high-quality care, including support for education, and guidelines for standards, and training. As safe, high-quality care requires an integrated approach, each element must be supported together, i.e., in an integrated manner to ensure that anaesthesia care reaches those who need it, and in the safest possible manner. Several important efforts have been undertaken globally to address and foster these elements, and resources to guide these processes exist for low- and middle-income countries to improve them. This review highlights both the needs and resources for safe and high-quality care that patients deserve.

Background

The population of Latin America is aging. Research from high-income countries demonstrates geriatric trauma is associated with higher morbidity and mortality. Very little research exists on geriatric patient (GP) injury prevalence in low-resource settings, like Bolivia.

Methods

Data were collected prospectively for 34 mo in the emergency departments of six trauma registry hospitals in Santa Cruz, Bolivia. Data were analyzed with Stata v14. Comparisons were made between GPs, defined as age greater than 65 y, and younger patients (YPs), with ages 18-64 y.

Results

Of n = 8796 trauma registry patients, 10.1% (n = 797) were aged 65 y or above, and n = 4989 (63.1%) were aged 18-64 y. The majority of GPs suffered falls (n = 543, 69.6%) versus 30.9% (n = 1541) of YPs (P < 0.001). Frequently, GPs had isolated injuries of the pelvis/hip (15.9% versus 1.4% YP, P < 0.0001) or upper extremity (15.8% versus 18.5% YP, P = 0.07), while YPs had a higher incidence of multiple injuries (YP 14.8% versus GP 8.4%, P < 0.001). While the majority of patients were discharged home (GP 43.0% versus YP 48.1%, P = 0.008), GPs were more likely to be admitted to the hospital (32.3% versus 22.3%, P < 0.001).

Conclusions

As life expectancy improves, the incidence of geriatric trauma will continue to increase. Understanding the characteristics associated with trauma in GP can allow for effective prevention methods, resource distribution, and discharge planning.

Introduction/purpose

The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited.

Methods

Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016.

Results

2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung’s, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%).

Conclusion

There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.