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Mattioli G, Louisma O, Wong MC, Palo F, Faticato MG, Petralia P. Non-standard approach to infants and children with megacolon: laparotomy and endorectal pull-through for diagnosis and treatment in difficult countries with low resources in a non-profit setting: return to the past Soave's ERPT. Minerva Pediatr (Torino) 2023; 75:576-582. [PMID: 30916520 DOI: 10.23736/s2724-5276.19.05487-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Hirschsprung's disease is an important cause of pediatric constipation with high risk of bacterial enterocolitis. Its diagnosis is histological and the suction biopsy is the gold standard. In resource-limited countries, the main diagnostic exam is the contrast enema and mini-invasive surgery lacks. We present the management of a cohort of patients with megacolon in Haiti, a low-resource country. METHODS Children with megacolon and fecal impaction admitted at St Damien Children Hospital in Port-Au-Prince in June, August and December 2017 were included. We considered only patients with an evident transition zone on contrast enema who underwent endorectal pull-through (ERPT). Short term complications were recorded. RESULTS Twenty children with clinical megacolon were admitted, eleven were included in the study. No suction rectal biopsy and intraoperative histological evaluation were performed. In ten children a Soave ERPT with anastomosis at 5POD was performed, in the other case a Boley primary anastomosis was preferred. One patient complicated with a peritonitis. No major complications were recorded. Colostomy was not considered a good option. CONCLUSIONS In developing countries, Soave ERPT with definitive anastomosis after few days could be considered a valid option. Colostomy is suggested only in case of scant general conditions or bad colon appearance.
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Affiliation(s)
- Girolamo Mattioli
- Department of Pediatric Surgery, Giannina Gaslini IRCCS Institute, University of Genoa, Genoa, Italy
| | - Osnel Louisma
- Department of Pediatric Surgery, Saint Damien Children Hospital, Port-au-Prince, Haiti
| | - Michela C Wong
- Department of Pediatric Surgery, Giannina Gaslini IRCCS Institute, University of Genoa, Genoa, Italy -
| | - Federico Palo
- Department of Pediatric Surgery, Giannina Gaslini IRCCS Institute, University of Genoa, Genoa, Italy
| | - Maria Grazia Faticato
- Department of Pediatric Surgery, Giannina Gaslini IRCCS Institute, University of Genoa, Genoa, Italy
| | - Paolo Petralia
- Giannina Gaslini IRCCS Institute, University of Genoa, Genoa, Italy
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Worlton TJ, Gunasingha RMKD, Atwood R, Johnson M, Uber IC. A Decade of Surgery Aboard the U.S. Naval Ship COMFORT (T-AH 20). Mil Med 2022; 188:usac278. [PMID: 36242546 DOI: 10.1093/milmed/usac278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/29/2022] [Accepted: 09/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The U.S. Naval Ship COMFORT has performed six humanitarian assistance and disaster relief mission since 2007. This paper describes the surgical volume per surgical specialty for five missions spanning 19 countries. MATERIALS AND METHODS Raw surgical case logs were analyzed for total case volume, total operating days, unanticipated return to operating room, and percentage of pediatric cases (<18 years old) for each country visited. RESULTS Total surgical volume for the five missions was 5,142. The countries most frequently visited were Columbia and Haiti with seven and five visits, respectively. General surgery, ophthalmology, and plastic surgery have had consistent volume over time. Orthopedic surgery volume has steadily decreased with the exception of the 2018 mission. CONCLUSION As volume in military treatment facilities declines, alternative sources of surgical volume for military surgeons are being examined. This paper highlights the historical volume which can inform future personnel planning requirements of U.S. Naval Ship COMFORT missions. With the exception of orthopedic surgery, surgical volume has remained consistent over the last decade. For future best practice, historical case data should be used to determine staffing needs on hospital ships and case logs and operating procedures and follow-up protocols should be standardized.
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Affiliation(s)
- Tamara J Worlton
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - Rex Atwood
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Mark Johnson
- Department of General Surgery, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
| | - Ian C Uber
- Department of Ophthalmology, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
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Leversedge C, Castro S, Appiani LMC, Kamal R, Shapiro L. Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving? World J Surg 2022; 46:2299-2309. [PMID: 35764890 PMCID: PMC9436850 DOI: 10.1007/s00268-022-06630-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 12/21/2022]
Abstract
Background The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.
Methods We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported. Results The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient. Conclusions There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06630-w.
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Affiliation(s)
- Chelsea Leversedge
- Stanford School of Medicine Department of Orthopaedic Surgery, VOICES Health Policy Research Center, 450 Broadway St, Redwood City, CA 94306 USA
| | - Samuel Castro
- Stanford School of Medicine, 291 Campus Drive, Palo Alto, CA 94305 USA
| | - Luis Miguel Castro Appiani
- Department of Orthopaedic Surgery, Hospital Clinica Biblica Aveinda, 14 Calle 1 Y Central, San José, Costa Rica USA
| | - Robin Kamal
- Stanford School of Medicine Department of Orthopaedic Surgery, VOICES Health Policy Research Center, 450 Broadway St, Redwood City, CA 94306 USA
| | - Lauren Shapiro
- School of Medicine Department of Orthopaedics, University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158 USA
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Sykes AG, Brill JB, Wallace JD, Lee C, Lewis PR, Henry MC, Christman MS, Casey KM, Bickler SW, Ignacio RC. Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy. Mil Med 2021; 188:usab500. [PMID: 34908148 DOI: 10.1093/milmed/usab500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/05/2021] [Accepted: 12/12/2021] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Alicia G Sykes
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Jason B Brill
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - James D Wallace
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Clara Lee
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Paul R Lewis
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Marion C Henry
- Division of Pediatric Surgery, The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL 60637, USA
| | - Matthew S Christman
- Department of Urology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Kevin M Casey
- Department of General Surgery, Cottage Hospital Santa Barbara, Santa Barbara, CA 93105, USA
| | - Stephen W Bickler
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, San Diego, CA 92093, USA
| | - Romeo C Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego, San Diego, CA 92093, USA
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Gaidry AD, Lizardo RE, Prieto JM, Brill JB, Hernandez AA, Moore HN, Henry MC, Ricca RL, Thangarajah H, Bickler SW, Ignacio RC. An Analysis of Essential Pediatric Surgical Cases Encountered During a Decade of Large-Scale Military Humanitarian Aid Missions. Mil Med 2020; 185:e2143-e2149. [PMID: 32856051 DOI: 10.1093/milmed/usaa177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Disease Control Priorities, 3rd Edition (DCP3) is an evidence-based, published resource that outlines essential procedures recommended for developing health care systems. These systems must consider various populations and the incidence of certain surgical conditions that require treatment. In relation to pediatric patients, the prevalence of certain surgical conditions encountered remains unclear in several low- and middle-income countries. Over the past 15 years, the USNS Mercy, one of the U.S. Navy's large hospital ships, has led the Pacific Partnership missions, which provide large-scale humanitarian aid throughout Southeast Asia. The data collected during these missions provide an opportunity to analyze the scope of pediatric operations performed in resource-limited countries. This analysis may assist in future planning for specific needs during military humanitarian missions. MATERIALS AND METHODS Surgical case data were prospectively collected during the six Pacific Partnership missions from 2006 to 2018. Demographic data were analyzed for all patients ≤8 years of age who underwent an operation. These data were retrospectively reviewed and all case logs were categorized by mission year, procedure-type, and host nation. Operations were classified based on 44 essential operations delineated in DCP3. Primary outcome was incidence of DCP3 essential operations. Secondary outcomes were perioperative complications. Standard statistical methods were performed for descriptive analysis. RESULTS A total of 3,209 major and minor operations were performed during 24 port visits in nine countries. Pediatric cases represented 1,117 (38%) of these procedures. Pediatric surgeons performed 291 (26%) of these cases. Based on DCP3 criteria, 789 pediatric operations (71%) were considered essential procedures. The most common DCP3-aligned procedures were cleft lip repair (432, 57%), hernia repair (207, 27%), and hydrocelectomy (60, 8%). Operative volume for pediatric surgery was highest during the 2008 mission (522 cases), when two pediatric surgeons were deployed, and lowest during the 2018 mission (five cases), when the mission focus was on education rather than surgical procedures and lack of pediatric cases referred by the host nation. Overall complication rate for pediatric cases was 1%. CONCLUSIONS This study represents the largest known analysis of military humanitarian assistance. Pediatric operations represented over one-third of the surgical volume during Pacific Partnership missions from 2006 to 2018. The majority of cases were DCP3-aligned and associated with a low complication rate. Future humanitarian aid missions and host nations should allocate appropriate medical and educational resources to treat DCP3 pediatric surgical diseases in low- and middle-income countries to support long-term capacity building while maintaining optimal surgical outcomes.
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Affiliation(s)
- Alicia D Gaidry
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Radhames E Lizardo
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - James M Prieto
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Jason B Brill
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Amy A Hernandez
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
| | - Hope N Moore
- Department of Surgery, University of California, 2221 Stockton Boulevard, Sacramento, CA 95817
| | - Marion C Henry
- Division of Pediatric Surgery, Department of Surgery, The University of Arizona Health Sciences, 1501 North Campbell Avenue, Room 4410, Tucson, AZ 85724
| | - Robert L Ricca
- Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708
| | - Hariharan Thangarajah
- Division of Pediatric Surgery, Rady Children's Hospital, Medical Office Building, 1st Floor, South 3030 Children's Way, San Diego, CA 92123
| | - Stephen W Bickler
- Division of Pediatric Surgery, Rady Children's Hospital, Medical Office Building, 1st Floor, South 3030 Children's Way, San Diego, CA 92123
| | - Romeo C Ignacio
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.,Division of Pediatric Surgery, Rady Children's Hospital, Medical Office Building, 1st Floor, South 3030 Children's Way, San Diego, CA 92123
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6
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Zitzman E, Berkley H, Jindal RM. Accountability in global surgery missions. BMJ Glob Health 2018; 3:e001025. [PMID: 30687523 PMCID: PMC6326286 DOI: 10.1136/bmjgh-2018-001025] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/07/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Elena Zitzman
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Holly Berkley
- Department of Obstetrics and Gynecology, Naval Medical Center San Diego, San Diego, California, USA
| | - Rahul M Jindal
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Abstract
PURPOSE Humanitarianism is by definition a moral of kindness, benevolence and sympathy extended to all human beings. In our view as surgeons working in underserved countries, humanitarianism means performing the best operation in the best possible circumstances with high income country (HIC) results and training in-country surgeons to do the same. Hernia Repair for the Underserved (HRFU), a not for profit organization, is developing a long term public health initiative for hernia surgery in Western Hemisphere countries. We report the progress of HRFUs methods to render humanitarian care. METHODS In a collaborative effort, Creighton University and the Institute for Latin American Concern developed an outpatient surgery site for hernia surgery in Santiago, Dominican Republic. Based on this experience, we developed a sustainable care model by recruiting American and European Hernia Society expert surgeons, staff members they recommended, building relationships with local and industry partners, and selecting local surgeons to be trained in mesh hernioplasty. HRFU then extended the care model to other Western Hemisphere countries. RESULTS Between 2004 and 2015, the HRFU elective hernia morbidity and mortality rates for 2052 hernia operations were 0.7 and 0%, respectively. This is consistent with outcomes from HICs and confirms the feasibility of a public health initiative based on the principles of the Preferential Option for the Poor. CONCLUSIONS HRFU has recorded HIC morbidity and mortality rates for hernia surgery in low and middle income countries and has initiated a new surgical training model for sustainability of effect.
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Flynn-O’Brien KT, Trelles M, Dominguez L, Hassani GH, Akemani C, Naseer A, Ntawukiruwabo IB, Kushner AL, Rothstein DH, Stewart BT. Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience. J Pediatr Surg 2016; 51:659-69. [PMID: 26454469 PMCID: PMC5860656 DOI: 10.1016/j.jpedsurg.2015.08.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/16/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams. METHODS Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death. RESULTS Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1year, use of general anesthesia with a definitive airway, and operation during conflict. CONCLUSION Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions.
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Affiliation(s)
- Katherine T. Flynn-O’Brien
- Department of Surgery, University of Washington, Seattle, WA, USA,Harborview Injury Prevention and Research Center, Seattle, WA, USA,Corresponding author at: University of Washington, Department of Surgery, 1959 NE Pacific St., Suite BB-487, P.O. Box 356410, Seattle, WA 98195-6410. Tel.: +1 206 543 3680. (K.T. Flynn-O’Brien)
| | - Miguel Trelles
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Lynette Dominguez
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Ghulam Hiadar Hassani
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,Boost General Hospital, Médecins sans Frontières, Lashkar-Gah, Afghanistan
| | - Clemence Akemani
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,General Referral Hospital, Médecins sans Frontières, Lubutu, Democratic Republic of the Congo
| | - Aamer Naseer
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium,Dargai DHQ Hospital, Dargai, Pakistan
| | - Innocent Bagura Ntawukiruwabo
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,General Referral Hospital, Médecins sans Frontières, Masisi, Democratic Republic of the Congo
| | - Adam L. Kushner
- Surgeons OverSeas (SOS), New York, NY, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Surgery, Columbia University, New York, NY, USA
| | - David H. Rothstein
- Department of Surgery, Women & Children's Hospital of Buffalo, NY, USA,Department of Surgery, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Barclay T. Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana,Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Corno AF. Paediatric and congenital cardiac surgery in emerging economies: surgical 'safari' versus educational programmes. Interact Cardiovasc Thorac Surg 2016; 23:163-7. [PMID: 27001675 DOI: 10.1093/icvts/ivw069] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/22/2016] [Indexed: 11/14/2022] Open
Abstract
To attract the interest of all people potentially involved in humanitarian activities in the emerging economies, in particular giving attention to the basic requirements of the organization of paediatric cardiac surgery activities, the requirements for a successful partnership with the local existing organizations and the basic elements of a patient-centred multidisciplinary integrated approach. Unfortunately, for many years, the interventions in the low and middle income countries were largely limited to short-term medical missions, not inappropriately nicknamed 'surgical safari', because of negative general and specific characteristics. The negative aspects and the limits of the short-term medical missions can be overcome only by long-term educational programmes. The most suitable and consistent models of long-term educational programmes have been combined and implemented with the personal experience to offer a proposal for a long-term educational project, with the following steps: (i) site selection; (ii) demographic research; (iii) site assessment; (iv) organization of surgical educational teams; (v) regular frequency of surgical educational missions; (vi) programme evolution and maturation; (vii) educational outreach and interactive support. Potential limits of a long-term educational surgical programme are: (i) financial affordability; (ii) basic legal needs; (iii) legal support; (iv) non-profit indemnification. The success should not be measured by the number of successful operations of any given mission, but by the successful operations that our colleagues perform after we leave. Considering that the children in need outnumber by far the people able to provide care, in this humanitarian medicine there should be plenty of room for cooperation rather than competition. The main goal should be to provide teaching to local staff and implement methods and techniques to support the improvement of the care of the patients in the long run. This review focuses on the organization of paediatric cardiac activities in the emerging economies, but 'the less privileged parts of the world' can be anywhere, not necessarily limited to economic constraints. Lack of diversity because of social, intellectual, educational and professional growth, the last consisting in cultural stagnation, is responsible for the lack of scientific progress and development.
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10
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Neff LP, Cannon JW, Charnock KM, Farmer DL, Borgman MA, Ricca RL. Elective pediatric surgical care in a forward deployed setting: What is feasible vs. what is reasonable. J Pediatr Surg 2016; 51:409-15. [PMID: 26585881 DOI: 10.1016/j.jpedsurg.2015.08.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/14/2015] [Accepted: 08/15/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the scope and outcomes of elective pediatric surgical procedures performed during combat operations. BACKGROUND The care of patients in Operation Enduring Freedom (OEF) includes elective humanitarian surgery on Afghan children. Unlike military reports of pediatric trauma care, there is little outcome data on elective pediatric surgical care during combat operations to guide treatment decisions. METHODS All elective surgical procedures performed on patients≤16years of age from May 2012 through April 2014 were reviewed. Procedures were grouped by surgical specialty and were further classified as single-stage (SINGLE) or multi-stage (MULTI). The primary endpoint was post-operative complications requiring further surgery, and the secondary endpoint was post-operative follow up. RESULTS A total of 311 elective pediatric surgical procedures were performed on 239 patients. Surgical specialties included general surgery, orthopedics, otolaryngology, ophthalmology, neurosurgery and urology. 178 (57%) were SINGLE while 133 (43%) were MULTI. Fifteen patients required 32 procedures for post-operative complications. Approximately half of all procedures were performed as outpatient surgery. Median length of stay for inpatient was 2.2days, and all patients survived to discharge. The majority of patients returned for outpatient follow-up (207, 87%), and 4 patients (1.7%) died after discharge. CONCLUSIONS Elective pediatric surgical care in a forward deployed setting is feasible; however, limitations in resources for perioperative care and rehabilitation mandate prudent patient selection particularly with respect to procedures that require prolonged post-operative care. Formal guidance on the process of patient selection for elective humanitarian surgery in these settings is needed.
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Affiliation(s)
- Lucas P Neff
- Department of Surgery, David Grant Medical Center, 101 Bodin Circle, Travis Air Force Base, California 94535; Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 95817; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814.
| | - Jeremy W Cannon
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia, Pennsylvania 19104.
| | - Kathryn M Charnock
- Department of Pediatrics, San Antonio Military Medical Center, 3551 Roger Brooke Dr. JBSA, Fort Sam Houston, Texas 78234.
| | - Diana L Farmer
- Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 95817.
| | - Matthew A Borgman
- Department of Pediatrics, San Antonio Military Medical Center, 3551 Roger Brooke Dr. JBSA, Fort Sam Houston, Texas 78234; Department of Pediatrics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814.
| | - Robert L Ricca
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, Virginia 23708.
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11
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Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery workforce in low- and middle-income countries: problems and priorities. Semin Pediatr Surg 2016; 25:32-42. [PMID: 26831136 DOI: 10.1053/j.sempedsurg.2015.09.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most of the world is in a surgical workforce crisis. While a lack of human resources is only one component of the myriad issues affecting surgical care in resource-poor regions, it is arguably the most consequential. This article examines the current state of the pediatric surgical workforce in low- and middle-income countries (LMICs) and the reasons for the current shortfalls. We also note progress that has been made in capacity building and discuss priorities going forward. The existing literature on this subject has naturally focused on regions with the greatest workforce needs, particularly sub-Saharan Africa (SSA). However, wherever possible we have included workforce data and related literature from LMICs worldwide. The pediatric surgeon is of course critically dependent on multi-disciplinary teams. Surgeons in high-income countries (HICs) often take for granted the ready availability of excellent anesthesia providers, surgically trained nurses, radiologists, pathologists, and neonatologists among many others. While the need exists to examine all of these disciplines and their contribution to the delivery of surgical services for children in LMICs, for the purposes of this review, we will focus primarily on the role of the pediatric surgeon.
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Affiliation(s)
- Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Suite 300, Portland, Oregon 97239.
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University School of Medicine. Columbus, Ohio
| | - Emmanuel A Ameh
- Division of Pediatric Surgery, National Hospital, Abuja, Nigeria
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12
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Abstract
Disparity still exists in the surgical care between sub-Saharan Africa and developed countries. Several international initiatives have been undertaken in the past decades to address the disparity. This study looks at the impact of these programs in child surgery in Sub-Saharan Africa. Review of electronic databases Medline and African Index Medicus on international partnerships for child surgery in Sub-Saharan Africa was undertaken. Four types of international initiatives were identified and consist of periodic medical missions; partnerships between foreign medical institutions or charities and local institutions; international health electives by surgical residents; and training of individual surgeons from developing countries in foreign institutions. The results of these efforts were variable, but sustainability and self-reliance of host nations were limited. Sociocultural factors, dearth of facilities, and lack of local governments' commitment were main impediments to effective local development or transfer of modern protocols of surgical management and improvement of pediatric surgical care at the host community level. Current initiatives may need improvements with better understanding of the sociocultural dynamics and local politics of the host nation, and improved host nation involvement and commitment. This may engender development of locally controlled viable services and sustainable high level of care.
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Addressing the Global Disparities in the Delivery of Pediatric Orthopaedic Services: Opportunities for COUR and POSNA. J Pediatr Orthop 2016; 36:89-95. [PMID: 26296220 DOI: 10.1097/bpo.0000000000000400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The burden of musculoskeletal conditions, especially injuries, is increasing in low-income and middle-income countries. Road traffic injuries have become epidemic. There are multiple barriers to accessing surgical services at both the individual (utilization) and the health system (availability) levels, and deficiencies in education and training of health providers. Specialty societies such as the Pediatric Orthopaedic Society of North America (POSNA) have an opportunity to play an important role through teaching and training. The POSNA Children's Orthopedics in Underserved Regions (COUR) committee has supported the Visiting Scholars Program, which invites surgeons from the developing world to attend a scientific meeting and facilitates the scholar's visit to North American pediatric orthopaedic centers. POSNA members have held global educational courses that support an educational exchange between lecturers and attendees. The COUR web site allows for submission of trip reports that document successes and obstacles experienced by members performing overseas clinical care and teaching. The web site also provides educational resources relevant to providing care in these environments. POSNA collaborates with other societies, such as the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons, to provide education in disaster management. In addition to increasing member involvement, specialty societies have the opportunity for continued data collection from overseas care, application of US registry data to disease processes in the developing world, and further collaboration with one another.
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Murray JS. Ethical considerations: pediatric short-term medical missions in developing countries. ISSUES IN COMPREHENSIVE PEDIATRIC NURSING 2015:1-11. [PMID: 26472081 DOI: 10.3109/01460862.2015.1088595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
For many years pediatric healthcare experts have debated how much benefit was derived by host nations from the well intentioned efforts of Pediatric Short-Term Medical Missions (STMMs). Most of the literature on STMMs, while limited, has focused on frameworks for the delivery of care. Today the focus of these endeavors is on the ethical implications. The purpose of this article is to describe how the focus of STMMs has changed over the past 15 years from delivery of care frameworks to ethical considerations.
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Affiliation(s)
- John S Murray
- a School of Professional Studies, Northwestern University , Chicago , Illinois , USA
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Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg 2015; 39:10-20. [PMID: 24682278 PMCID: PMC4179995 DOI: 10.1007/s00268-014-2516-0] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed. Methods A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included. Results Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited. Conclusions Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.
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Berry NS. Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical missions in Sololá, Guatemala. Soc Sci Med 2014; 120:344-51. [DOI: 10.1016/j.socscimed.2014.05.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 04/29/2014] [Accepted: 05/05/2014] [Indexed: 12/01/2022]
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Cavallo JA, Ousley J, Barrett CD, Baalman S, Ward K, Borchardt M, Thomas JR, Perotti G, Frisella MM, Matthews BD. A material cost-minimization analysis for hernia repairs and minor procedures during a surgical mission in the Dominican Republic. Surg Endosc 2013; 28:747-66. [PMID: 24162140 DOI: 10.1007/s00464-013-3253-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Expenditures on material supplies and medications constitute the greatest per capita costs for surgical missions. We hypothesized that supply acquisition at non-profit organization (NPO) costs would lead to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for hernia repairs and minor procedures during a surgical mission in the Dominican Republic. METHODS Items acquired for a surgical mission were uniquely QR-coded for accurate consumption accounting. Both NPO and US academic institution unit costs were associated with each item in an electronic inventory system. Medication doses were recorded and QR codes for consumed items were scanned into a record for each sampled procedure. Mean material costs and cost-savings ± SDs were calculated in US dollars for each procedure type. Cost-minimization analyses between the NPO and the US academic institution platforms for each procedure type ensued using a two-tailed Wilcoxon matched-pairs test with α = 0.05. Item utilization analyses generated lists of most frequently used materials by procedure type. RESULTS The mean cost-savings of supply acquisition at NPO costs for each procedure type were as follows: $482.86 ± $683.79 for unilateral inguinal hernia repair (n = 13); $332.46 ± $184.09 for bilateral inguinal hernia repair (n = 3); $127.26 ± $13.18 for hydrocelectomy (n = 9); $232.92 ± $56.49 for femoral hernia repair (n = 3); $120.90 ± $30.51 for umbilical hernia repair (n = 8); $36.59 ± $17.76 for minor procedures (n = 26); and $120.66 ± $14.61 for pediatric inguinal hernia repair (n = 7). CONCLUSION Supply acquisition at NPO costs leads to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for inguinal hernia repair, hydrocelectomy, umbilical hernia repair, minor procedures, and pediatric inguinal hernia repair during a surgical mission in the Dominican Republic. Item utilization analysis can generate minimum-necessary material lists for each procedure type to reproduce cost-savings for subsequent missions.
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Affiliation(s)
- Jaime A Cavallo
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO, 63110, USA,
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Rothstein DH. Impressive achievements of a 2009 humanitarian mission by the US Naval Ship Comfort. J Pediatr Surg 2012; 47:1783. [PMID: 22974624 DOI: 10.1016/j.jpedsurg.2012.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 05/03/2012] [Indexed: 10/27/2022]
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