Publications

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.

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.

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 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.

Background

We sought to understand the challenges in accessing pediatric surgical care in the context of the “three delays” model at the Pediatric Surgery Outpatient Clinic (PSOPC) at a tertiary hospital in Kampala, Uganda.

Materials and methods

An outpatient database was established at the weekly PSOPC. A survey regarding prior healthcare visits and barriers to care was additionally administered to clinic patients and inpatients.

Results

Patients first sought healthcare a median of 56 d before the current visit to the PSOPC. A majority (52%) of patients first sought care at another health facility, and 17% of those surveyed had presented to the PSOPC three or more times for their current medical issue. Of 240 patients with a new issue or due for their next surgery, 10% were admitted to the ward, with only 54% receiving definitive care. Included in the most commonly needed surgeries for PSOPC patients were herniotomy (16% inguinal; 14.9% umbilical), orchiopexy (6.3%), posterior sagittal anorectoplasty (6.3%), and colostomy closure (4.4%), with the range of patient ages at the time of presentation reflecting delays in care. Patient expenditures associated with travel to the hospital showed inpatients coming from significantly further away, with higher costs of travel and need to borrow or sell assets to cover travel costs, when compared with PSOPC patients.

Conclusions

Patients face significant delays in accessing and receiving definitive surgical care. Associated burdens associated with these delays place patients at risk for catastrophic health expenditures. Infrastructure and capacity development are necessary for improvement in pediatric surgical care.

Background

Communication is the foundation of any patient-doctor relationship. Patients who are unable to communicate effectively with physicians because of language barriers may face disparities in accessing orthopaedic care and in the evaluation and treatment of musculoskeletal symptoms. We evaluated whether Spanish-speaking patients face disparities scheduling appointments with orthopaedists via the telephone.

Methods

From the American Academy of Orthopaedic Surgeons (AAOS) web site, we randomly selected 50 orthopaedic surgeons’ offices in California specializing in knee surgery. The investigator called eligible offices using a script to request an appointment for a hypothetical Spanish-speaking or English-speaking 65-year-old man with knee pain. The caller randomly selected the patient’s primary language for this first call. A second call was placed a week later requesting an appointment for an identical patient who spoke the alternate language.

Results

There was no significant difference between Spanish-speaking and English-speaking patients’ access to appointments with an orthopaedic surgeon (p = 0.8256). Thirty-six English-speaking patients and 35 Spanish-speaking patients were offered an appointment. Twenty-eight Spanish-speaking patients were instructed to bring a friend or family member who could translate for them, 3 were told that the provider spoke sufficient Spanish to communicate without the need for an interpreter, and 4 were told that an interpreter would be made available.

Conclusions

We did not detect a disparity between Spanish-speaking and English-speaking patients’ access to appointments with an orthopaedic surgeon. However, 80% of Spanish-speaking patients were asked to rely on nonqualified interpreters for their orthopaedic appointment. This study suggests that orthopaedic offices in California depend heavily on ad hoc interpreters rather than professional interpretation services. It also highlights potential barriers to the provision of qualified interpreters. Additional study is warranted to assess how this lack of adequate utilization of medical interpreters affects the patient-doctor relationship, the quality of care received, and the financial burden on the health system.

Clinical relevance

Optimizing the care that we provide to our patients is a goal of every orthopaedic surgeon. We highlight the importance of utilizing professional interpreters as a means to reduce health-care disparities and overall health-care costs, as well as the importance of improving reimbursement and infrastructure for physicians to utilize qualified interpreters in caring for their limited-English-proficient patients.

Background

In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries.

Methods

Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation.

Results

One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia).

Conclusions

Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.

Objective

To determine social factors associated with advanced stone disease (defined as unilateral stone burden >2 cm) at time of presentation to a regional stone referral center. Little is known about social determinants of urolithiasis. We hypothesize that socioeconomic factors impact kidney stone severity at intake to referral centers.

Methods

A retrospective review of the prospectively collected data from the Registry for Stones of the Kidney and Ureter from 2015 to 2018 was conducted to evaluate patient characteristics predictive of having a large (>2 cm) unilateral kidney stone. Data on patient age, gender, body mass index, diabetes, race, language, education level, infection, distance, income, referring regional urologist density, American Society of Anesthesiologists score, and stone analysis were evaluated.

Results

Complete imaging and patient variable data was present in 650 of 1142 patients including 197 patients with unilateral stone burden >2 cm. On multivariate analysis, obesity, lower education level, increased distance from the referral center, and symptoms of infection predicted for unilateral stone burden greater than 2 cm. Among 191 patients with stone analysis data present, stone type, income, and urologist density predicted for unilateral stone burden greater than 2 cm.

Conclusion

In addition to known biological risk factors, patients with lower education levels and from regions of lower mean income were found to be more likely to present to our tertiary care center with stone burden greater than 2 cm. More research is needed to elucidate the social and societal determinants of advanced stone disease and the impact this has on population costs for stone treatment.

Purpose of review

Two-thirds of the world’s population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children’s surgery.

Recent findings

Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.

Summary

Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children’s surgery in LMICs. Capacity-building and scale up of children’s surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children’s surgical care worldwide.

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.

Simulation is relatively new in many low-income countries. We describe the challenges encountered, solutions deployed, and the costs incurred while establishing two simulation centers in Uganda. The challenges we experienced included equipment costs, difficulty in procurement, lack of context-appropriate curricula, unreliable power, limited local teaching capacity, and lack of coordination among user groups. Solutions we deployed included improvisation of equipment, customization of low-cost simulation software, creation of context-specific curricula, local administrative support, and creation of a simulation fellowship opportunity for local instructors. Total costs for simulation setups ranged from US $165 to $17,000. For centers in low-income countries trying to establish simulation programs, our experience suggests that careful selection of context-appropriate equipment and curricula, engagement with local and international collaborators, and early emphasis to increase local teaching capacity are essential. Further studies are needed to identify the most cost-effective levels of technological complexity for simulation in similar resource-constrained settings.

Objective

To estimate how many children and adolescent worldwide do not have access to surgical care.

Methods

We estimated the number of children and adolescents younger than 19 years worldwide without access to safe, affordable and timely surgical care, by using population data for 2017 from the United Nations and international data on surgical access in 2015. We categorized countries by World Bank country income group and obtained the proportion of the population with no access to surgical care from a study by the Commission on Global Surgery.

Findings

An estimated 1.7 billion (95% credible interval: 1.6-1.8) children and adolescents worldwide did not have access to surgical care in 2017. Lack of access occurred overwhelmingly in low- and middle-income countries where children and adolescents make up a disproportionately large fraction of the population. Moreover, 453 million children younger than 5 years did not have access to basic life-saving surgical care. According to Commission on Global Surgery criteria, less than 3% of the paediatric population in low-income countries and less than 8% in lower-middle-income countries had access to surgical care.

Conclusion

There were substantial gaps in the availability of surgical services for children worldwide, particularly in low- and middle-income countries. Future research should focus on developing specific measures for assessing paediatric surgical access, delivery and outcomes and on clarifying how limited surgical access in the poorest parts of the world affects child health, especially mortality in children younger than 5 years.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

Background

Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world’s population receives approximately 73.6% of the world’s total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators.

Material and methods

Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care.

Results

One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%).

Conclusions

This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.