Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Surgically Correctable Congenital Anomalies: Reducing Morbidity and Mortality in the First 8000 Days of Life.

BACKGROUND: Congenital anomalies are a leading cause of morbidity and mortality worldwide. We aimed to review the common surgically correctable congenital anomalies with recent updates on the global disease burden and identify the factors affecting morbidity and mortality. METHOD: A literature review was done to assess the burden of surgical congenital anomalies with emphasis on those that present within the first 8000 days of life. The various patterns of diseases were analyzed in both low- and middle-income countries (LMIC) and high-income countries (HIC). RESULTS: Surgical problems such as digestive congenital anomalies, congenital heart disease and neural tube defects are now seen more frequently. The burden of disease weighs more heavily on LMIC. Cleft lip and palate has gained attention and appropriate treatment within many countries, and its care has been strengthened by global surgical partnerships. Antenatal scans and timely diagnosis are important factors affecting morbidity and mortality. The frequency of pregnancy termination following prenatal diagnosis of a congenital anomaly is lower in many LMIC than in HIC. CONCLUSION: Congenital heart disease and neural tube defects are the most common congenital surgical diseases; however, easily treatable gastrointestinal anomalies are underdiagnosed due to the invisible nature of the condition. Current healthcare systems in most LMICs are still unprepared to tackle the burden of disease caused by congenital anomalies. Increased investment in surgical services is needed.

Evaluating pediatric car safety compliance in motor vehicle collisions: Identifying high-risk groups for improper restraint usage.

PURPOSE: To identify patient factors associated with improper restraint usage and worse trauma outcomes for pediatric patients involved in motor vehicle collisions (MVCs). METHODS: Retrospective study performed at a Level I pediatric trauma center for patients (≤18 yr) evaluated after MVC between 2008 and 2018. The Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) levels based on the patient's home address. Trauma registry data was correlated to ADI and used to analyze appropriate restraint usage by NSD. Proper restraint practices were defined based on national guidelines and state laws. Demographics and clinical outcomes were also analyzed. Chi-square analysis with Bonferroni corrections was used to assess the association of ADI, race, and ethnicity with proper restraint usage. RESULTS: Among 1152 patients included, approximately 50% were male, the median age was 7 years [IQR 4-10], and 53% were of Hispanic ethnicity. Hispanic patients comprised 73% of children in ADI quintile 5 (greatest NSD), yet only 26% of children in ADI quintile 1 (least NSD). No differences were observed across clinical data and outcomes. Hispanic children <8 yr were significantly less likely to be in a car seat/booster seat compared to non-Hispanic children (OR 0.69, 95% CI 0.50-0.95, p = 0.025). Furthermore, those with greatest NSD (ADI quintile 5) had the largest proportion of unrestrained patients (21%, see Fig. 1). CONCLUSION: Hispanic children, especially those who require infant or booster seats (<8 yr), and children living in areas with greater neighborhood socioeconomic disadvantage demonstrated poorer restraint practices. ADI can successfully identify high-risk groups for targeted injury prevention programs and improved compliance in the most vulnerable neighborhoods. TYPE OF STUDY: Retrospective Study.

Elemental, fatty acid, and protein composition of appendicoliths.

Appendicoliths are commonly found obstructing the lumen of the appendix at the time of appendectomy. To identify factors that might contribute to their formation we investigated the composition of appendicoliths using laser ablation inductively coupled plasma mass spectroscopy, gas chromatography, polarized light microscopy, X-ray crystallography and protein mass spectroscopy. Forty-eight elements, 32 fatty acids and 109 human proteins were identified within the appendicoliths. The most common elements found in appendicoliths are calcium and phosphorus, 11.0 ± 6.0 and 8.2 ± 4.2% weight, respectively. Palmitic acid (29.7%) and stearate (21.3%) are the most common fatty acids. Some stearate is found in crystalline form-identifiable by polarized light microscopy and confirmable by X-ray crystallography. Appendicoliths have an increased ratio of omega-6 to omega-3 fatty acids (ratio 22:1). Analysis of 16 proteins common to the appendicoliths analyzed showed antioxidant activity and neutrophil functions (e.g. activation and degranulation) to be the most highly enriched pathways. Considered together, these preliminary findings suggest oxidative stress may have a role in appendicolith formation. Further research is needed to determine how dietary factors such as omega-6 fatty acids and food additives, redox-active metals and the intestinal microbiome interact with genetic factors to predispose to appendicolith formation.

Fostering Sustainable Biomedical Research Training in Mozambique: A Spin-Off of the Medical Education Partnership Initiative.

Background: The further development of research capacity in low- and middle-income countries is critical to the delivery of evidence-based healthcare, the design of sound health policy and effective resource allocation. Research capacity is also critical for the retention of highly skilled faculty and staff and for institutional internationalization. Objectives: We summarize the accomplishments, challenges and legacy of a five-year program to train biomedical researchers entitled "Enhanced Advanced Biomedical Research Training for Mozambique (EABRTM)". Methods: A program conducted from 2015-2021 built upon the Medical Education Partnership Initiative to develop research capacity at Eduardo Mondlane University (UEM) and allied institutions. The project included design and implementation of postgraduate training programs and bolstered physical and human research infrastructure. Findings: The program supported development and implementation of UEM's first doctoral (Bioscience and Public Health) and master (Biosciences) programs with 31 and 23 students enrolled to date, respectively. Three master programs were established at Lúrio University from which 176/202 (87.1%) and 107/202 (53.0%) students obtained a Postgraduate Diploma or master's degree, respectively. Scholarships were awarded to 39 biomedical researchers; 13 completed master degrees, one completed a PhD and five remain in doctoral studies. Thirteen administrative staff and four biomedical researchers were trained in research administration and in biostatistics, respectively. A total of 119 courses and seminars benefited 2,142 participants. Thirty-five manuscripts have been published to date in peer-reviewed international journals of which 77% are first-authored by Mozambicans and 44% last-authored by Africans. Sustainability was achieved through 59 research projects awarded by international agencies, totaling $16,363,656.42 and funds ($ 7,319,366.11) secured through 2025. Conclusions: The EABRTM program substantially increased research and mentorship capacity and trained a new generation of biostatisticians and research administrators. These programmatic outcomes significantly increased the confidence of early stage Mozambican researchers in their ability to successfully pursue their career goals.

Prevalence and Severity of Burn Scars in Rural Mozambique.

BACKGROUND: Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need. METHODS: Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention. RESULTS: Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures. CONCLUSION: Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Defining Surgical Workforce Density Targets to Meet Child and Neonatal Mortality Rate Targets in the Age of the Sustainable Development Goals: A Global Cross-Sectional Study.

OBJECTIVES: To reduce preventable deaths of newborns and children, the United Nations set a target rate per 1000 live births of 12 for neonatal mortality (NMR) and 25 for under-5 mortality (U5MR). The purpose of this paper is to define the minimum surgical workforce needed to meet these targets and evaluate the relative impact of increasing surgeon, anesthesia, and obstetrician (SAO) density on reducing child mortality. METHODS: We conducted a cross-sectional study of 192 countries to define the association between surgical workforce density and U5MR as well as NMR using unadjusted and adjusted B-spline regression, adjusting for common non-surgical causes of childhood mortality. We used these models to estimate the minimum surgical workforce to meet the sustainable development goals (SDGs) for U5MR and NMR and marginal effects plots to determine over which range of SAO densities the largest impact is seen as countries scale-up SAO workforce. RESULTS: We found that increased SAO density is associated with decreased U5MR and NMR (P < 0.05), adjusting for common non-surgical causes of child mortality. A minimum SAO density of 10 providers per 100,000 population (95% CI: 7-13) is associated with an U5MR of < 25 per 1000 live births. A minimum SAO density of 12 (95% CI: 9-20) is associated with an NMR of < 12 per 1000 live births. The maximum decrease in U5MR, on the basis of our adjusted B-spline model, occurs from 0 to 20 SAO per 100,000 population. The maximum decrease in NMR based on our adjusted B-spline model occurs up from 0 to 18 SAO, with additional decrease seen up to 80 SAO. CONCLUSIONS: Scale-up of the surgical workforce to 12 SAO per 100,000 population may help health systems meet the SDG goals for childhood mortality rates. Increases in up to 80 SAO/100,000 continue to offer mortality benefit for neonates and would help to achieve the SDGs for neonatal mortality reduction.

Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries.

BACKGROUND: Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. METHODS: Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. RESULTS: An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. CONCLUSIONS: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Integrating traffic safety data with area deprivation index: A method to better understand the causes of pediatric pedestrian versus automobile collisions.

BACKGROUND: The purpose of this study was to identify clinical and traffic factors that influence pediatric pedestrian versus automobile collisions (P-ACs) with an emphasis on health care disparities. METHODS: A retrospective review was performed of pediatric (18 years or younger) P-ACs treated at a Level I pediatric trauma center from 2008 to 2018. Demographic, clinical, and traffic scene data were analyzed. Area deprivation index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) based on home addresses. Traffic scene data from the California Statewide Integrated Traffic Records System were matched to clinical records. Traffic safety was assessed by the streetlight coverage, the proximity of the collision to home addresses, and sidewalk coverage. Descriptive statistics and univariate analysis for key variables and outcomes were calculated using Kruskal-Wallis, Wilcoxon, χ 2 , or Fisher's exact tests. Statistical significance was attributed to p values of <0.05. RESULTS: Among 770 patients, the majority were male (65%) and Hispanic (54%), with a median age of 8 years (interquartile range, 4-12 years). Hispanic patients were more likely to live in more disadvantaged neighborhoods than non-Hispanic patients (67% vs. 45%, p < 0.01). There were no differences in clinical characteristics or outcomes across ADI quintiles. Using the Statewide Integrated Traffic Records System (n = 272), patients with more NSD were more likely injured during dark streetlight conditions (15% vs. 4% least disadvantaged; p = 0.04) and within 0.5 miles from home ( p < 0.01). Pedestrian violations were common (65%). During after-school hours, 25% were pedestrian violations, compared with 12% driver violations ( p = 0.02). CONCLUSION: A larger proportion of Hispanic children injured in P-ACs lived in neighborhoods with more socioeconomic disadvantage. Hispanic ethnicity and NSD are each independently associated with P-ACs. Poor streetlight conditions and close proximity to home were associated with the most socioeconomically disadvantaged neighborhoods. This research may support targeted prevention programs to improve pedestrian safety in children. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Laparoscopic Surgery Requiring Abdominal Insufflation in Patients With Congenital Heart Disease.

OBJECTIVE: To determine if patients with congenital heart disease are undergoing laparoscopic surgery requiring abdominal insufflation and to compare the outcomes of these procedures with those who underwent an open surgical approach. DESIGN, SETTING, PARTICIPANTS: This was a retrospective study using the National Inpatient Sample from 2006 to 2014. Individuals with congenital heart disease who underwent at least one of six selected surgical procedures (laparoscopic or open) were included in the study. Subgroup analysis was performed on patients with Fontan palliation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was to determine the frequency with which congenital heart disease patients undergo laparoscopic surgery requiring abdominal insufflation compared with open surgery. Secondary outcomes included all-cause in-hospital mortality and in-hospital length of stay. Of the 5,527 patients included, nearly half underwent laparoscopic surgery (46.3%), and 128 (2.3%) had single-ventricle circulation. All-cause mortality was significantly higher for those who underwent open surgery compared with the laparoscopic approach (3.6% v 0.9%; odds ratio [OR], 4.0 [2.6-6.3]; p < 0.0001). Subgroup analysis of patients with Fontal palliation older than five years showed 30 (42%) underwent laparoscopic surgery and there was no mortality difference between the laparoscopic and open approaches (OR, 1.4 [0.2-21.3], p = 0.8). Length of stay was significantly shorter for patients undergoing laparoscopic compared with open surgery (median three days [interquartile range, two-five] v six days [three-13], p < 0.0001). CONCLUSIONS: Individuals with congenital heart disease are being offered laparoscopic surgery that requires abdominal insufflation. All-cause mortality and length of stay were higher for patients who underwent open surgical operations.

Challenges in Oncologic Preparedness: A Retrospective Review of Incident Surgical Cancers During Pacific Partnership Missions, 2008-2016.

INTRODUCTION: For over 30 years, the USNS Mercy hospital ship has provided surgical care on multiple humanitarian aid and disaster relief missions. During these missions, surgical support varies according to host nation needs, and the operative treatment of cancer patients remains controversial. We report the number of incidentally discovered surgical oncologic cases treated aboard the USNS Mercy on four missions and discuss challenges regarding oncologic care on these missions. MATERIALS AND METHODS: Between 2008 and 2016, operative cases and surgical pathology results from four multinational humanitarian missions were analyzed according to organ system, patient's geographic location, and diagnosis. Primary outcomes were total number and proportion of malignant cases, analyzed yearly and over all four missions. Secondary outcomes were malignant diagnoses by organ system and host nation health capacities (based on indicators from the WHO). RESULTS: A total of 2,767 operations were performed during 18 port visits in 8 countries in Southeast Asia. In total, 1,193 pathology specimens (surgical biopsies, fine needle aspirations, etc.) were obtained. Overall malignancy rate across all organ systems was 9%. Yearly malignancy rates ranged from 2% to 13%. The highest malignancy rates were found in thyroid (33%), breast (20%), and parotid and salivary gland cases (19%). All host nations had operational strategies for cancer in place (n = 8, 100%), but few had national infrastructures to treat noncommunicable diseases (n = 2, 25%). CONCLUSIONS: Despite current policies to screen out cancer patients on USNS Mercy missions, 9% of surgical biopsies were malignant. Cancer management during these missions presents a unique challenge because of limited resources for surgery, chemoradiotherapy, and follow-up care. Contingency plans must be considered to provide completion of care for these patients whose cancers are discovered incidentally. Furthermore, an understanding of host nation capabilities in relation to medical and surgical care is crucial to providing treatment in resource-limited areas.

Just Stick a Scope in: Laparoscopic Ventriculoperitoneal Shunt Placement in the Pediatric Reoperative Abdomen.

BACKGROUND: Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS: A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS: A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS: Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy.

INTRODUCTION: Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. MATERIALS AND METHODS: Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. RESULTS: A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician-gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. CONCLUSIONS: Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and Middle-Income Countries: A Global Study.

BACKGROUND: Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. METHODS: To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20-40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. RESULTS: Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p < 0.01 for each model). When accounting for concomitant increases in surgical volume, scale-up of the surgical workforce to 20-40 SAO/100,000 could potentially prevent between 262,709 (95% CI 229,643-295,434) and 519,629 (465,046-573,919) under 5 deaths annually. The majority (61%) of deaths averted would be neonatal deaths. CONCLUSION: Scale up of surgical workforce may substantially decrease childhood mortality rates around the world. Our analysis suggests that scale-up of surgical delivery through increase in the SAO workforce could prevent over 500,000 children from dying before the age of 5 annually. This would represent significant progress toward meeting global child mortality reduction targets.

Extremes of age are associated with differences in the expression of selected pattern recognition receptor genes and ACE2, the receptor for SARS-CoV-2: implications for the epidemiology of COVID-19 disease.

BACKGROUND: Older aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes. METHODS: Using a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2. RESULTS: Extremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins. CONCLUSIONS: Assessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.

Design and Implementation of Postgraduate Programs in Health in a Resource-Limited Setting in Mozambique (The Lúrio University).

PURPOSE: To describe the strategies used to design and implement three postgraduate programs at Lúrio University (UniLúrio), a resource-limited setting, in northern Mozambique. METHODS: We conducted a longitudinal, descriptive case study from 2011 to 2018 in two phases: 1) needs assessment (2011-2012), 2) implementation strategies (2013-2018), taking into account innovations whenever necessary. RESULTS: Several obstacles and barriers to the establishment of postgraduate programs were identified. These included a lack of a core curricula aimed at postgraduate programs, shortage of human resources for teaching and mentorship, limited teaching and research infrastructures, limited financial resources, and lack of administrative capacity. With the support of the Medical Education Partnership Initiative (MEPI), three Master degree programs were designed and implemented. During the period of 2013-2018, UniLúrio enrolled 202 students, distributed as follows: Master degree in Tropical Medicine and Global Health (55), Master degree in Health Professional Education (99), and Master degree in Nutrition and Food Security (48). Of those, 152 (75.2%) obtained a Postgraduate Diploma as they did not present a master dissertation, 89 (44.0%) obtained their Master degree, 30 (14.8%) dropped out, and 20 (9.9%) are awaiting decision. UniLurio's staff trained a Master's degree or a Postgraduate Diploma in 34 (16.8%) and 15 (7.4%), respectively. Our strategies allowed us to improve research capacity building, and set the basis for long-term sustainability by allowing for the establishment of other postgraduate programs, and offered UniLurio a strong role in its internationalization. CONCLUSION: By sharing multiple resources, long-lasting partnerships were established with multiple institutions, and competency-based training and postgraduate studies management were developed. Research and eLearning were leveraged, retention and faculty development was enhanced, and some inequalities within the country were reduced. These strategies and innovations can be applied to other resource-limited settings, allowing the scaleup of health professional's training and research capacity building.

Assessment of Surgical Care Provided in National Health Services Hospitals in Mozambique: The Importance of Subnational Metrics in Global Surgery.

INTRODUCTION: Surgery plays a critical role in sustainable healthcare systems. Validated metrics exist to guide implementation of surgical services, but low-income countries (LIC) struggle to report recommended metrics and this poses a critical barrier to addressing unmet need. We present a comprehensive national sample of surgical encounters from a LIC by assessing the National Health Services of Mozambique. MATERIAL AND METHODS: A prospective cohort of all surgical encounters from Mozambique's National Health Service was gathered for all provinces between July and December 2015. Primary outcomes were timely access, provider densities for surgery, anesthesiology, and obstetrics (SAO) per 100,000 population, annualized surgical procedure volume per 100,000, and postoperative mortality (POMR). Secondary outcomes include operating room density and efficiency. RESULTS: Fifty-four hospitals had surgical capacity in 11 provinces with 47,189 surgeries. 44.9% of Mozambique's population lives in Districts without access to surgical services. National SAO density was 1.2/100,000, ranging from 0.4/100,000 in Manica Province to 9.8/100,000 in Maputo City. Annualized national surgical case volume was 367 procedures/100,000 population, ranging from 180/100,000 in Zambezia Province to 1,897/100,000 in Maputo City. National POMR was 0.74% and ranged from 0.23% in Maputo Province to 1.78% in Niassa Province. DISCUSSION: Surgical delivery in Mozambique falls short of international targets. Subnational deficiencies and variations between provinces pose targets for quality improvement in advancing national surgical plans. This serves as a template for LICs to follow in gathering surgical metrics for the WHO and the World Bank and offers short- and long-term targets for surgery as a component of health systems strengthening.

Regulation of the Nfkbiz Gene and Its Protein Product IkBζ in Animal Models of Sepsis and Endotoxic Shock.

Sepsis is a life-threatening condition that arises from a poorly regulated inflammatory response to pathogenic organisms. Current treatments are limited to antibiotics, fluid resuscitation, and other supportive therapies. New targets for monitoring disease progression and therapeutic interventions are therefore critically needed. We previously reported that lipocalin-2 (Lcn2), a bacteriostatic mediator with potent proapoptotic activities, was robustly induced in sepsis. Other studies showed that Lcn2 was a predictor of mortality in septic patients. However, how Lcn2 is regulated during sepsis is poorly understood. We evaluated how IkBζ, an inducer of Lcn2, was regulated in sepsis using both the cecal ligation and puncture (CLP) and endotoxemia (lipopolysaccharide [LPS]) animal models. We show that Nfkbiz, the gene encoding IkBζ, was rapidly stimulated but, unlike Lcn2, whose expression persists during sepsis, mRNA levels of Nfkbiz decline to near basal levels several hours after its induction. In contrast, we observed that IkBζ expression remained highly elevated in septic animals following CLP but not LPS, indicating the occurrence of a CLP-specific mechanism that extends IkBζ half-life. By using an inhibitor of IkBζ, we determined that the expression of Lcn2 was largely controlled by IkBζ. Altogether, these data indicate that the high IkBζ expression in tissues likely contributes to the elevated expression of Lcn2 in sepsis. Since IkBζ is also capable of promoting or repressing other inflammatory genes, it might exert a central role in sepsis.

Inclusion of Children's Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children's Surgery.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.