A prospective observational study of postoperative follow-ups and outcomes at a nonprofit, internationally supported pediatric surgery center in Guatemala.

BACKGROUND: Global surgical access is unequally distributed, with the greatest surgical burden in low- and middle-income countries, where surgical care is often supplemented by nongovernmental organizations. Quality data from organizations providing this care are rarely collected or reported. The Moore Pediatric Surgery Center in Guatemala City, Guatemala, is unique in that it offers a permanently staffed, freestanding pediatric surgical center. Visiting surgical teams supplement the local permanent staff by providing a broad range of pediatric subspecialty surgical and anesthesia care. AIM: The aim of this study was to collect and report the incidence of completed postoperative follow-up visits and outcome measures at this nonprofit, internationally supported surgery center. METHODS: De-identified demographic and postoperative outcome data were collected from each routinely scheduled, one-week pediatric surgical mission trip and incorporated into an electronic data collection system. Emphasis was placed on identification of completed postoperative visits and associated perioperative complications. After 27 months of data collection, results were analyzed to identify and quantify trends in patient follow-ups and postoperative outcomes. RESULTS: Over 27 months, 1639 pediatric surgical procedures were performed and included in data analysis. The percentage of completed postoperative day-1 follow-up visits was 99.1%, and seven complications were identified out of these 1624 cases (postoperative complication rate of 0.4%). The percentage of completed first postoperative visits after discharge was 93.3%, and 67 complications were identified out of these 1530 cases (postoperative complication rate of 4.4%). CONCLUSION: Our data show a high rate of postoperative follow-up visits completed and low perioperative complication rates similar to those of high-income countries. Our data suggest that The Moore Surgery Center model of care offers an alternative to the short-term visiting surgical model by incorporating the local system and allows for improved follow-up, outcomes analysis, and high quality of care.

Anesthesia Infrastructure and Resources in Bangladesh.

BACKGROUND: Monitoring improvements in nationwide anesthesia capacity over time is critical to ensuring that population anesthesia needs are being met and identifying areas for targeted health systems interventions. Anesthesia resources in Bangladesh were previously measured using a cross-sectional nationwide hospital-based survey in 2012. No follow-up studies have been conducted since then. METHODS: A follow-up cross-sectional study was performed in 16 public hospitals; 8 of which are public district hospitals, and 8 are medical college (tertiary) hospitals in Bangladesh. A survey tool assessing hospital anesthesia capacity, developed by Vanderbilt University Medical Center, was utilized. Nationwide data were obtained from the Ministry of Health and Family Welfare and from the Bangladesh Society of Anaesthesiologists. Institutional Review Board approvals were obtained in the United States and Bangladesh, and informed consent was waived. RESULTS: Bangladesh has 952 anesthesiologists (0.58 anesthesiologists per 100,000 people), which represents a modest increase from 850 anesthesiologists in 2012. Significant improvements in electricity and clean water availability have occurred since the 2012 survey. Severe deficiencies in patient safety and monitoring equipment (eg, pulse oximetry, electrocardiography, blood pressure, anesthesia machines, and intubation materials) were noted, primarily at the district hospital level. CONCLUSIONS: Despite modest improvements in certain anesthesia metrics over the past several years, the public health care system in Bangladesh still suffers from substantial deficiencies in anesthesia care.

Randomized controlled trial comparing the supraglottic airway to use of an endotracheal tube in sinonasal surgery.

BACKGROUND: The supraglottic airway (SGA) represents an alternative to endotracheal intubation (endotracheal tube [ETT]) in many types of ambulatory surgery. Adoption of the SGA has progressed slowly in sinonasal surgery due to concerns about airway protection. The purpose of this study was to compare quality of life measures and indices of airway protection between patients undergoing sinonasal surgery who were ventilated via an SGA or ETT. METHODS: Patients undergoing outpatient sinonasal surgery were enrolled into a randomized, single-blind study in which patients would be ventilated with either an SGA or ETT. At the first postoperative visit, a symptom severity and quality of life questionnaire was completed. Additional objective metrics were extracted from the anesthesia record. RESULTS: A total of 102 patients were enrolled; 49 assigned to the SGA group and 53 assigned to the ETT group. No significant differences in swallowing function or cough were identified. SGA patients reported more difficulty returning to a normal diet (p = 0.03) with a trend toward reduced throat pain (p = 0.07) and improved phonation (p = 0.06). No significant difference in perioperative oxygen desaturations, emesis, recovery time, or airway blood penetration were identified. CONCLUSION: While the use of the SGA results in patient diet modification postoperatively, it may also be associated with a reduction in throat pain and dysphonia. SGA use had no appreciable effect on postanesthesia recovery times, oxygen desaturations, or emesis. Use of the SGA in sinonasal surgery appears to be a safe and reliable option for airway management in selected adult patients undergoing routine ambulatory sinonasal surgery.

Surgical Outreach for Children by International Humanitarian Organizations: A Review.

Low- and middle-income countries carry a disproportionate share of the global burden of pediatric surgical disease and have limited local healthcare infrastructure and human resources to address this burden. Humanitarian efforts that have improved or provided access to necessary basic or emergency surgery for children in these settings have included humanitarian assistance and disaster relief, short-term surgical missions, and long-term projects such as building pediatric specialty hospitals and provider networks. Each of these efforts may also include educational initiatives designed to increase local capacity. This article will provide an overview of pediatric humanitarian surgical outreach including reference to available evidence-based analyses of these platforms and make recommendations for surgical outreach initiatives for children.

A geospatial evaluation of timely access to surgical care in seven countries.

OBJECTIVE: To assess the consistent availability of basic surgical resources at selected facilities in seven countries. METHODS: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. FINDINGS: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. CONCLUSION: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Creating a Global Acute Care Surgery Fellowship to Meet International Need.

INTRODUCTION: Existing Acute Care Surgery (ACS) fellowships are positioned to develop well-trained surgeons with specific skills to facilitate improvements in care delivery in Global ACS. Many resident and fellowship programs offer clinical electives that expose trainees to operative experiences, exposing trainees to the needs in resource-challenged settings. However, most lack a focus on long-term development and research designed to enhance the country's local skills, capability, and capacity. The Global Acute Care Surgery (Global ACS) fellowship produces a surgeon who focuses on capacity building and systems development across the world. METHODS: At Vanderbilt University, the current American Association for the Surgery of Trauma-Acute Care Surgery (AAST-ACS) fellowship was adapted to create an academic Global Acute Care Surgery (Global ACS) fellowship. This fellowship specifically enhances fellowship trainee's skills in needs assessment and performing research to facilitate the development and implementation of trauma and acute care surgery systems in low- and middle income countries. This research will foster context-appropriate data, collected and based in low- and middle-income countries, to guide practice and policy. RESULTS AND CONCLUSION: Two fellows have completed the Global ACS fellowship at Vanderbilt University. The fellowship requirements, clinical skills, project development and overall goals are outlined within the article. Challenges, funding, and mentorship must also be addressed to develop a comprehensive fellowship. A sample two-year timeline is provided to complete the fellowship track and meet the defined goals. A structured global acute care surgery fellowship enables fellows to reduce the surgical burden of disease and contribute to surgical systems development at both local and international levels by creating meaningful research and developing sustainable change in LMIC countries.

A Systematic Review and Meta-Analysis of the Global Burden of Chronic Pain Without Clear Etiology in Low- and Middle-Income Countries: Trends in Heterogeneous Data and a Proposal for New Assessment Methods.

BACKGROUND: The global burden of chronic pain is projected to be large and growing, in concert with the burden of noncommunicable diseases. This is the first systematic review and meta-analysis of the prevalence of chronic pain without clear etiology in general, elderly, and working populations of low- and middle-income countries (LMICs). METHODS: We collected and reported data using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, excluding acute pain or pain associated with a concurrent medical condition. One hundred nineteen publications in 28 LMICs were identified for systematic review; the 68 reports that focused on general adult populations (GP), elderly general populations (EGP), or workers (W) were evaluated using mixed-effects regression meta-analysis. RESULTS: Average chronic pain prevalence is reported as a percentage of the population, with 95% confidence interval for each pain type and population (GP, EGP, and W; NA is equal to not available): unspecified chronic pain (34[26-42], 62[41-81], and NA); low back pain (21[15-27], 28[16-42], and 52[26-77]); headache (42[27-58], 30[19-43], and 51[13-88]); chronic daily headache (5[3-7], 5[1-12], and 10[0-33]); chronic migraine (GP 12[6-19]); chronic tension type headache (GP 8[3-15]); musculoskeletal pain (25[19-33], 44[28-62], and 79[60-94]); joint pain (14[11-18], 34[16-54], and NA); chronic pelvic/prostatitis pain (GP 4[0-14]); temporomandibular disorder (35[4-78], 8[0-24], and NA); abdominal pain (EGP 17[6-32]); fibromyalgia (Combined GP, EGP, W 6[5-7]); and widespread pain (7[1-18], 19[8-32], and NA). Chronic low back pain and musculoskeletal pain were 2.50 (1.21-4.10) and 3.11 (2.13-4.37) times more prevalent among W, relative to a GP. Musculoskeletal, joint, and unspecified pain were 1.74 (1.03-2.69), 2.36 (1.09-4.02), and 1.83 (1.13-2.65) times more prevalent among the EGP, relative to a GP. There was significant heterogeneity among studies for all pain types (I > 90%). CONCLUSIONS: Chronic pain is prevalent in LMICs, and where there was sufficient evidence, generally more prevalent in EGP and W. This meta-analysis reveals the spectrum of chronic pain without clear etiology in LMICs. Steps should be taken to reduce heterogeneity in the assessment of global chronic pain. Possible actions may include standardization of chronic pain definition, widespread adoption of validated questionnaires across cultures, attention to inequitably burdened populations, and inclusion of queries regarding known associations of chronic pain with social and psychological factors that, in combination, increase the global burden of noncommunicable disease and disability.

Analysis of trauma admission data at an urban hospital in Maputo, Mozambique.

BACKGROUND: Trauma is a major public health concern. Worldwide, injuries resulted in 4.8 million deaths in 2013, an increase of 11 % since 1990. The majority of deaths from trauma in low-and middle-income countries occur in a pre-hospital setting. Morbidity from trauma contributes significantly to disability in these countries. Mozambique has experienced a rise in injury-related morbidity and mortality. Efforts are underway to prioritize surgical and anesthesiology care in the post-2015 Global Surgery agenda that will build on momentum of the Millennium Development Goals. Injury surveillance remains vital to defining priorities and implementing policy changes. METHODS: We performed a cross-sectional study between June and September, 2010 at the Hospital Central de Maputo (HCM). Data were collected on all patients admitted to the HCM emergency surgical services with a diagnosis of trauma. We describe patient characteristics and mechanism of traumatic injury by calculating simple proportions (for dichotomous or categorical variables) or medians with interquartile ranges (IQR) for continuous variables. Multivariable logistic regression analysis was used to estimate the mechanisms of trauma most associated with alcohol consumption. RESULTS: A total of 517 patients were approached for inclusion in this study. Of these, 441 (91.5 %) participants were followed from admission until discharge. Three hundred twenty-four participants (73.5 %) were male. The most common age group was 20-29 years old. The three principal mechanisms of injury were road traffic injury, fighting, and falls, accounting for 74 % of injuries recorded. Traumatic injury involving alcohol consumption was nine times more likely to occur at a recreation/sporting event (OR 9.0, 95 % CI 3.01-27.13, p ≤ 0.0001). CONCLUSIONS: As Mozambique prepares to respond to the post-2015 international development agenda, urgent action is required to scale-up its national injury surveillance networks. Injury prevention efforts in Mozambique should focus attention on improving road safety regulations and their implementation, as well as on interventions targeting violence reduction and the reduction of alcohol consumption at sporting events.