Developing a cardiac surgery unit in the Caribbean: A reflection.

BACKGROUND AND AIM: Access to specialized cardiac surgery is a problem in emerging countries. Here, we reflect on the approach we used to establish a cardiac surgery unit in Trinidad and Tobago. METHODS: The program started in 1993 with monthly visits by a team from Bristol Heart Institute. A group of local doctors, nurses, and perfusionists were identified for training, and a senior nurse moved to the island to start a teaching program. The visiting support was gradually reduced, and the local team gained independence in managing the service in 2006. RESULTS: The initial low volume surgery increased to around 380 cases a year with the implementation of comprehensive service in 2006. Most patients required coronary artery bypass graft (CABG). In-hospital mortality declined from 5% in the nascent years to below 2% thereafter. In the last 5 years (2015-2019), 1764 patients underwent surgery (mean age 59.6 ± 10.8 years, 66% male). The majority were East-Indian-Caribbean (79.1%) or Afro-Caribbean (16.7%), half had diabetes, and two-thirds hypertension (EuroScore II 1.8 ± 1.9). The majority (1363 patients) underwent CABG (99.5% off-pump; conversion to on-pump 1.5%). The mean number of grafts was 2.5 ± 0.7 with 98.5% and 23.1% receiving one and two or more arterial grafts, respectively. In-hospital mortality was 1.1%, re-exploration for bleeding 2%, stroke 0.1%, mediastinitis 0.2%. The length of the postoperative hospital stay was 5.8 ± 2 days. CONCLUSION: Frequent outside visits complemented by training in an overseas center, and transfer of knowledge proved to be an effective strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards.

Successful pregnancy in a CKD patient on a low-protein, supplemented diet: an opportunity to reflect on CKD and pregnancy in Mexico, an emerging country.

Pregnancy is probably the most important challenge in young women with chronic kidney disease (CKD). The challenge is greater in developing countries, in which access to dialysis is uneven, and prenatal care for CKD patients is not uniformly available. This case report summarizes some of the challenges faced by pregnant CKD women in a developing country. A 35-year-old woman, affected by an undiagnosed kidney disease, experienced preeclampsia at 24 years of age, and started dialysis in emergency at age 31 in the context of severe preeclampsia in her second pregnancy. Following slow recovery of kidney function, after 18 months of dialysis she started a moderately restricted, supplemented, low-protein diet, which allowed her to discontinue dialysis. A few months after dialysis discontinuation, she started a new pregnancy in the presence of severely reduced kidney function (serum creatinine 4.6 mg/dl at the last pre-pregnancy control). Interestingly, she discontinued nephrology and nutritional follow-up, mainly because she was worried that she would be discouraged from continuing the pregnancy, but also because she continued to feel well. She self-managed her diet in pregnancy and delivered a healthy baby, with normal intrauterine growth, at term; while the last laboratory data confirmed the presence of severe kidney function impairment, she is still dialysis-free at the time of the present report. Her story, with its happy ending, underlines the importance of dedicated programs for CKD pregnancies in developing countries and confirms the safety of moderately protein-restricted diets in pregnancy.

Fifteen Years' Experience of the Brazilian Osteosarcoma Treatment Group (BOTG): A Contribution from an Emerging Country.

PURPOSE: Little information is available regarding the tumor features, prognostic factors, and treatment results in children and adolescents and young adults (AYAs) with osteosarcoma diagnosed in developing countries. We reviewed the results of three observational cohorts of osteosarcoma patients treated in an emerging country. METHODS: A total of 604 patients below the age of 30 years with high-grade osteosarcoma were prospectively enrolled in the Brazilian Osteosarcoma Treatment Group (BOTG) studies III, IV, and V. Gender, age, time from onset of symptoms to diagnosis, primary tumor site, presence or absence of metastases at diagnosis, tumor size, type of surgery (limb-sparing or amputation), treatment protocol, and histological response were correlated with survival. RESULTS: The estimated 5-year overall survival and event-free survival (EFS) rates for the 553 eligible patients were 49% and 39% respectively; of the 390 non-metastatic patients included in the total, overall- and event-free survival were 59% and 48% respectively. Metastases at diagnosis, primary tumor site, type of surgery, and histological response were significant predictors of overall survival and EFS in univariate and multivariate analysis, whereas tumor size and treatment protocol lost prognostic significance in multivariate analysis. CONCLUSION: We report on the outcome of three consecutive studies for the treatment of osteosarcoma carried out in Brazil over 15 years. Although the survival rates presented are below those reported in current literature, it represents the result of a favorable experience gathered from the national collaborative work.