Publications

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class="top__label">University of California San Francisco</label> <ul id="nav_header_top" class="top__links"> <li class="links__item"> <a href="https://globalhealthsciences.ucsf.edu/" title="Visit IGHS - link opens in new tab" target="_blank" >Visit IGHS</a> </li> <li class="links__item"> <a href="https://globalsurgery.org/fundraising" title="Support CHESA" >Support CHESA</a> </li> </ul> </div> </div> </header> <main class="Publications"> <section class="HeadingTitleSection row"> <h1 class="HeadingTitleSection__title">Publications</h1> <div class="HeadingTitleSection__row"> <p class="HeadingTitleSection__description">The list below contains publications by CHESA members, including faculty, fellows and collaborators. </p> </div> <form id="search_form" method="GET" class="HeadingTitleSection__form"> <input aria-label="Search publications by author or keyword" type="search" name="search" placeholder="Search publications by author or keyword" value="" class="form__input"> <button 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</button> </li> <li class="list__item" data-key="1"> <button class="item__button " aria-label="Select category Advocacy" data-slug="advocacy" data-number="109"> <span class="button__content">Advocacy</span> </button> </li> <li class="list__item" data-key="2"> <button class="item__button " aria-label="Select category Anesthesia" data-slug="anesthesia" data-number="55"> <span class="button__content">Anesthesia</span> </button> </li> <li class="list__item" data-key="3"> <button class="item__button " aria-label="Select category CHESA Fellows" data-slug="fellows-publications" data-number="17"> <span class="button__content">CHESA Fellows</span> </button> </li> <li class="list__item" data-key="4"> <button class="item__button " aria-label="Select category Critical Care" data-slug="critical-care" data-number="10"> <span class="button__content">Critical Care</span> </button> </li> <li class="list__item" data-key="5"> <button class="item__button " aria-label="Select category Data Science" 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class="item__button " aria-label="Select category OHNS" data-slug="ohns" data-number="1"> <span class="button__content">OHNS</span> </button> </li> <li class="list__item" data-key="11"> <button class="item__button " aria-label="Select category Ophthalmology" data-slug="opth" data-number="2"> <span class="button__content">Ophthalmology</span> </button> </li> <li class="list__item" data-key="12"> <button class="item__button " aria-label="Select category Orthopedics" data-slug="ortho" data-number="11"> <span class="button__content">Orthopedics</span> </button> </li> <li class="list__item" data-key="13"> <button class="item__button " aria-label="Select category Pain & analgesia" data-slug="pain" data-number="1"> <span class="button__content">Pain & analgesia</span> </button> </li> <li class="list__item" data-key="14"> <button class="item__button " aria-label="Select category Patient Safety" data-slug="safety" data-number="32"> <span class="button__content">Patient Safety</span> </button> </li> <li class="list__item" data-key="15"> <button class="item__button " aria-label="Select category Pediatrics" data-slug="pediatrics" data-number="63"> <span class="button__content">Pediatrics</span> </button> </li> <li class="list__item" data-key="16"> <button class="item__button " aria-label="Select category Surgery" data-slug="surgery" data-number="154"> <span class="button__content">Surgery</span> </button> </li> <li class="list__item" data-key="17"> <button class="item__button " aria-label="Select category Trauma" data-slug="trauma" data-number="18"> <span class="button__content">Trauma</span> </button> </li> <li class="list__item" data-key="18"> <button class="item__button " aria-label="Select category Urology" data-slug="urology" data-number="9"> <span class="button__content">Urology</span> </button> </li> <li class="list__item" data-key="19"> <button class="item__button " aria-label="Select category Workforce" data-slug="workforce" data-number="28"> <span class="button__content">Workforce</span> </button> </li> </ul> <button class="content__button content__button--next" aria-label="Scroll right"><img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/></button> </div> </div> <div class="row__select row__select--categories"> <label class="select__label">Category:</label> <div class="select__box"> <select name="category"> <option value="" selecteed >All publications</option> <option value="advocacy" >Advocacy</option> <option value="anesthesia" >Anesthesia</option> <option value="fellows-publications" >CHESA Fellows</option> <option value="critical-care" >Critical Care</option> <option value="data" >Data Science</option> <option value="education" >Education</option> <option value="neurosurgery" >Neurosurgery</option> <option value="nursing" >Nursing</option> <option value="obstetrics" >Obstetrics</option> <option value="ohns" >OHNS</option> <option value="opth" >Ophthalmology</option> <option value="ortho" >Orthopedics</option> <option value="pain" >Pain & analgesia</option> <option value="safety" >Patient Safety</option> <option value="pediatrics" >Pediatrics</option> <option value="surgery" >Surgery</option> <option value="trauma" >Trauma</option> <option value="urology" >Urology</option> <option value="workforce" >Workforce</option> </select> <svg xmlns="http://www.w3.org/2000/svg" fill="none" viewBox="0 0 20 20"><path stroke="#10214b" stroke-linecap="round" stroke-linejoin="round" stroke-width="1.5" d="m16 7-6 6-6-6"/></svg> </div> </div> <div class="row__select row__select--orderby"> <label class="select__label">Sort by:</label> <div class="select__box"> <select name="orderby"> <option value="newest" selected >Newest</option> <option value="oldest" >Oldest</option> </select> <svg xmlns="http://www.w3.org/2000/svg" fill="none" viewBox="0 0 20 20"><path stroke="#10214b" stroke-linecap="round" stroke-linejoin="round" stroke-width="1.5" d="m16 7-6 6-6-6"/></svg> </div> </div> </div> <div class="PublicationsSection__content"> <div class="content__wrapper"> <div class="wrapper__items"> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Identification of urological anomalies associated with anorectal malformation in southwestern Uganda: Limitations and opportunities.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/39147608" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Oyania F</span>, <span>Eze N</span>, <span>Aturinde M</span>, <span>Ullrich S</span>, <span>Mwesigwa M</span>, <span>Ozgediz DE</span></p> <div class="PublicationTile__description"><p><em>Journal of pediatric urology</em><br />PubDate: 2024 Aug 7<br /><span>PUBMED: 39147608</span> ; <span>DOI: 10.1016/j.jpurol.2024.07.027</span> ; <span>PII: S1477-5131(24)00420-0</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgb(113,0,226);color: #ffffff">Urology</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Introduction</h3> <p>Anorectal malformations (ARMs) may be associated with congenital anomalies affecting other body parts namely vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb (VACTERL) with varying incidences of 7%-60% . Genitourinary defects might occur approximately in 50% of all patients with anorectal malformations hence patients should be evaluated from birth to rule out these defects.</p> <h3>Objective</h3> <p>To identify urological anomalies associated with anorectal malformation in southwestern Uganda.</p> <h3>Study design</h3> <p>This was a descriptive retrospective cohort study conducted at our regional referral hospital in Southwestern Uganda involving patients who have undergone surgical correction of ARMs between June 2021 and July 2023.</p> <h3>Results</h3> <p>The overall prevalence of renal anomalies in our study patient population was 18.05%. Of those with ARM-associated renal anomalies, Specific anomalies included; renal agenesis (6.8%), hydronephrosis, (4.5%), duplex collecting system (3.8%), crossed fused kidney (1.5%), and ectopic kidney (0.75%). (Table) DISCUSSION: We found that the prevalence of ARM-associated renal anomalies was 18.05%, and the commonest anomaly was unilateral agenesis (6.8%) similar to other studies. Previous data have shown renal anomalies are common anomalies in ARM. While the exact values vary across studies, they all concluded that the rate of associated anomalies is extremely high in ARMs and warrants a thorough preoperative investigation once the ARMs are detected. This finding therefore underscores the importance of thorough evaluation and a multidisciplinary approach of care and follow-up system for ARM management including urologists even when the children are asymptomatic now. The main limitation of our study was missing information on patients’ charts, we were not able to get the diagnosis since most patients didn’t have their discharge forms at the time of evaluation.</p> <h3>Conclusion</h3> <p>ARM associated with renal anomalies may remain undiagnosed and asymptomatic. Those identified as asymptomatic need to be followed in a multidisciplinary fashion including pediatric urologists.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Understanding the Burden of Pediatric Traumatic Injury in Uganda: A Multicenter, Prospective Study.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38870654" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Thomas HS</span>, <span>Emmanuel A</span>, <span>Kayima P</span>, <span>Ajiko MM</span>, <span>Grabski DF</span>, <span>Situma M</span>, <span>Kakembo N</span>, <span>Ozgediz DE</span>, <span>Sabatini CS</span></p> <div class="PublicationTile__description"><p><em>The Journal of surgical research</em><br />PubDate: 2024 Aug<br /><span>PUBMED: 38870654</span> ; <span>DOI: 10.1016/j.jss.2024.04.043</span> ; <span>PII: S0022-4804(24)00212-9</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single">Multicenter Study</li> <li class="terms__single" style="background-color: rgba(0,186,55,0.15);color: #00d130">Orthopedics</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Introduction</h3> <p>Traumatic injury is responsible for eight million childhood deaths annually. In Uganda, there is a paucity of comprehensive data describing the burden of pediatric trauma, which is essential for resource allocation and surgical workforce planning. This study aimed to ascertain the burden of non-adolescent pediatric trauma across four Ugandan hospitals.</p> <h3>Methods</h3> <p>We performed a descriptive review of four independent and prospective pediatric surgical databases in Uganda: Mulago National Referral Hospital (2012-2019), Mbarara Regional Referral Hospital (2015-2019), Soroti Regional Referral Hospital (SRRH) (2016-2019), and St Mary’s Hospital Lacor (SMHL) (2016-2019). We sub-selected all clinical encounters that involved trauma. The primary outcome was the distribution of injury mechanisms. Secondary outcomes included operative intervention and clinical outcomes.</p> <h3>Results</h3> <p>There was a total of 693 pediatric trauma patients, across four hospital sites: Mulago National Referral Hospital (n = 245), Mbarara Regional Referral Hospital (n = 29), SRRH (n = 292), and SMHL (n = 127). The majority of patients were male (63%), with a median age of 5 [interquartile range = 2, 8]. Chiefly, patients suffered blunt injury mechanisms, including falls (16.2%) and road traffic crashes (14.7%) resulting in abdominal trauma (29.4%) and contusions (11.8%). At SRRH and SMHL, from which orthopedic data were available, 27% of patients suffered long-bone fractures. Overall, 55% of patients underwent surgery and 95% recovered to discharge.</p> <h3>Conclusions</h3> <p>In Uganda, non-adolescent pediatric trauma patients most commonly suffer injuries due to falls and road traffic crashes, resulting in high rates of abdominal trauma. Amid surgical workforce deficits and resource-variability, these data support interventions aimed at training adult general surgeons to provide emergency pediatric surgical care and procedures.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Letter to the Editor: Are low- and middle-income countries achieving the Lancet commission global benchmark for surgical volumes? A systematic review.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38944810" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Davis GL</span>, <span>Suzuki E</span>, <span>Rose J</span></p> <div class="PublicationTile__description"><p><em>World journal of surgery</em><br />PubDate: 2024 Jun 30<br /><span>PUBMED: 38944810</span> ; <span>DOI: 10.1002/wjs.12268</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Letter</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgba(65,0,229,0.15);color: #0b00e5">Workforce</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Treatment abandonment in children with Wilms tumor at a national referral hospital in Uganda.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38926234" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Nanteza S</span>, <span>Yap A</span>, <span>Stephens CQ</span>, <span>Kambagu JB</span>, <span>Kisa P</span>, <span>Kakembo N</span>, <span>Fadil G</span>, <span>Nimanya SA</span>, <span>Okello I</span>, <span>Naluyimbazi R</span>, <span>Mbwali F</span>, <span>Kayima P</span>, <span>Ssewanyana Y</span>, <span>Grabski D</span>, <span>Naik-Mathuria B</span>, <span>Langer M</span>, <span>Ozgediz D</span>, <span>Sekabira J</span></p> <div class="PublicationTile__description"><p><em>Pediatric surgery international</em><br />PubDate: 2024 Jun 27<br /><span>PUBMED: 38926234</span> ; <span>PMC: PMC11208238</span> ; <span>DOI: 10.1007/s00383-024-05744-7</span> ; <span>PII: 10.1007/s00383-024-05744-7</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgb(113,0,226);color: #ffffff">Urology</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Introduction</h3> <p>The incidence of pediatric Wilms’ tumor (WT) is high in Africa, though patients abandon treatment after initial diagnosis. We sought to identify factors associated with WT treatment abandonment in Uganda.</p> <h3>Methods</h3> <p>A cohort study of patients < 18 years with WT in a Ugandan national referral hospital examined clinical and treatment outcomes data, comparing children whose families adhered to and abandoned treatment. Abandonment was defined as the inability to complete neoadjuvant chemotherapy and surgery for patients with unilateral WT and definitive chemotherapy for patients with bilateral WT. Patient factors were assessed via bivariate logistic regression.</p> <h3>Results</h3> <p>137 WT patients were included from 2012 to 2017. The mean age was 3.9 years, 71% (n = 98) were stage III or higher. After diagnosis, 86% (n = 118) started neoadjuvant chemotherapy, 59% (n = 82) completed neoadjuvant therapy, and 55% (n = 75) adhered to treatment through surgery. Treatment abandonment was associated with poor chemotherapy response (odds ratio [OR] 4.70, 95% confidence interval [CI] 1.30-17.0) and tumor size > 25 cm (OR 2.67, 95% CI 1.05-6.81).</p> <h3>Conclusions</h3> <p>Children with WT in Uganda frequently abandon care during neoadjuvant therapy, particularly those with large tumors with poor response. Further investigation into the factors that influence treatment abandonment and a deeper understanding of tumor biology are needed to improve treatment adherence of children with WT in Uganda.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Assessment of the Surgical Oncology Case Volume Within the Public Sector in Tanzania</h2> <a href="https://ascopubs.org/doi/10.1200/GO.23.00316" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>bwa</span>, <span>MD</span>, <span>MSc</span>, <span>Rukia Hamid</span>, <span>MD</span>, <span>MMed</span>, <span>Deo Hando</span>, <span>MD</span>, <span>MMed</span>, <span>Charles Komba</span>, <span>MD</span>, <span>MMed</span>, <span>Ally Mwanga</span>, <span>MD</span>, <span>MMed</span>, <span>Peter Mbele</span>, <span>MD</span>, <span>MMed</span>, <span>Paul Itule</span>, <span>MD</span>, <span>MMed</span>, <span>Joshua Jackson</span>, <span>MD</span>, <span>MMed</span>, <span>Mungeni Misidai</span>, <span>MD</span>, <span>MMed</span>, <span>Cameron Gaskill</span>, <span>MD</span>, <span>MPH and Doruk Ozgediz</span>, <span>MD</span>, <span>MSc</span></p> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgba(65,0,229,0.15);color: #0b00e5">Workforce</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><section id="abs-sec-1"> <h3>Purpose</h3> <div role="paragraph">Surgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania.</div> </section> <section id="abs-sec-2"> <h3>Methods</h3> <div role="paragraph">Operative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country.</div> </section> <section id="abs-sec-3"> <h3>Results</h3> <div role="paragraph">In total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery.</div> </section> <section id="abs-sec-4"> <h3>Conclusion</h3> <div role="paragraph">In this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.</div> </section> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38446259" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Okello I</span>, <span>Stephens CQ</span>, <span>Kakembo N</span>, <span>Kisa P</span>, <span>Nimanya S</span>, <span>Yap A</span>, <span>Wesonga AS</span>, <span>Naluyimbazi R</span>, <span>Kayima P</span>, <span>Ssewanyana Y</span>, <span>Ozgediz D</span>, <span>Sekabira J</span></p> <div class="PublicationTile__description"><p><em>Pediatric surgery international</em><br />PubDate: 2024 Mar 6<br /><span>PUBMED: 38446259</span> ; <span>PMC: PMC10917857</span> ; <span>DOI: 10.1007/s00383-024-05639-7</span> ; <span>PII: 10.1007/s00383-024-05639-7</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Purpose</h3> <p>Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes.</p> <h3>Methods</h3> <p>A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05.</p> <h3>Results</h3> <p>A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK.</p> <h3>Conclusion</h3> <p>Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Equitable Roadmap: Navigating Challenges for Black Anesthesiologists in the United States</h2> <a href="https://csahq.org/2024/02/26/equitable-roadmap-navigating-challenges-for-black-anesthesiologists-in-the-united-states/" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Betelehem Asnake</span>, <span>MD</span>, <span>MS</span></p> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Editorial</li> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> <li class="terms__single" style="background-color: rgb(103,42,178);color: #ffffff">Anesthesia</li> <li class="terms__single" style="background-color: rgba(65,0,229,0.15);color: #0b00e5">Workforce</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Safeguarding children through pediatric surgical care in war and humanitarian settings: a call to action for pediatric patients in Gaza.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38440223" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Muthumani A</span></p> <div class="PublicationTile__description"><p><em>World journal of pediatric surgery</em><br />PubDate: 2024<br /><span>PUBMED: 38440223</span> ; <span>PMC: PMC10910480</span> ; <span>DOI: 10.1136/wjps-2023-000719</span> ; <span>PII: wjps-2023-000719</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Results of a Pilot Virtual Microsurgery Course for Plastic Surgeons in LMICs.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38348462" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Davis GL</span>, <span>Abebe MW</span>, <span>Vyas RM</span>, <span>Rohde CH</span>, <span>Coriddi MR</span>, <span>Pusic AL</span>, <span>Gosman AA</span></p> <div class="PublicationTile__description"><p><em>Plastic and reconstructive surgery. Global open</em><br />PubDate: 2024 Feb<br /><span>PUBMED: 38348462</span> ; <span>PMC: PMC10860934</span> ; <span>DOI: 10.1097/GOX.0000000000005582</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Background</h3> <p>The Plastic Surgery Foundation’s Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program seeks to expand surgical capacity worldwide through mentorship and training for local plastic surgeons. This study aims to define the need for microsurgery training among SHARE global fellows and describe results of a pilot course.</p> <h3>Methods</h3> <p>Ten participants of the SHARE Virtual Microsurgical Skills Course were asked to complete an anonymous survey. Pre- and post-course response rates were 100% and 50.0%, respectively.</p> <h3>Results</h3> <p>There was a high incidence of microsurgical problems encountered in the clinical setting. Resource availability was varied, with high access to loupes (100%), yet limited access to microsurgery instruments (50%), medications (40%), operating microscope (20%), skilled nursing (0%) and appropriate peri-operative care settings (0%). Participants identified vessel preparation, instrument selection, and suture handling as priority learning objectives for a microsurgery skills course. Post-course satisfaction with learning objectives was high (60% “very good,” 40% “excellent”). Participants reported high levels of improvement in suture handling (Likert 4.60±0.55), end-to-end anastomosis (4.40±0.55), instrument selection (4.20±0.45), vessel preparation (4.20±0.45), and economy of motion (4.20±0.45).</p> <h3>Conclusions</h3> <p>This study demonstrates a high frequency of reconstructive problems encountered by global fellows yet low access to appropriate resources to perform microsurgical procedures. Initial results from a pilot virtual microsurgery course demonstrate very high satisfaction and high self-rated improvement in key microsurgical skills. The virtual course is an effective and accessible format for training surgeons in basic microsurgery skills and can be augmented by providing longitudinal opportunities for remote feedback.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38190831" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Arias AV</span>, <span>Lintner-Rivera M</span>, <span>Shafi NI</span>, <span>Abbas Q</span>, <span>Abdelhafeez AH</span>, <span>Ali M</span>, <span>Ammar H</span>, <span>Anwar AI</span>, <span>Adabie Appiah J</span>, <span>Attebery JE</span>, <span>Diaz Villalobos WE</span>, <span>Ferreira D</span>, <span>González-Dambrauskas S</span>, <span>Irfan Habib M</span>, <span>Lee JH</span>, <span>Kissoon N</span>, <span>Tekleab AM</span>, <span>Molyneux EM</span>, <span>Morrow BM</span>, <span>Nadkarni VM</span>, <span>Rivera J</span>, <span>Silvers R</span>, <span>Steere M</span>, <span>Tatay D</span>, <span>Bhutta AT</span>, <span>Kortz TB</span>, <span>Agulnik A</span>, <span>Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network on behalf of the PALISI Global Health Subgroup</span></p> <div class="PublicationTile__description"><p><em>The Lancet. Global health</em><br />PubDate: 2024 Feb<br /><span>PUBMED: 38190831</span> ; <span>DOI: 10.1016/S2214-109X(23)00537-5</span> ; <span>PII: S2214-109X(23)00537-5</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single">Review</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> <li class="terms__single" style="background-color: rgba(0,122,81,0.15);color: #007059">Critical Care</li> <li class="terms__single" style="background-color: rgba(0,0,0,0.25);color: #666666">Nursing</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p>The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37802018" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Starr N</span>, <span>Tadesse M</span>, <span>Igwebuike C</span>, <span>Sherefa K</span>, <span>Genetu A</span>, <span>Aregawi Y</span>, <span>Zewdu E</span>, <span>Tamirat D</span>, <span>Desalegn M</span>, <span>Getahun B</span>, <span>Harris H</span>, <span>Zemenfes D</span></p> <div class="PublicationTile__description"><p><em>The Journal of surgical research</em><br />PubDate: 2024 Jan<br /><span>PUBMED: 37802018</span> ; <span>DOI: 10.1016/j.jss.2023.08.017</span> ; <span>PII: S0022-4804(23)00389-X</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(0,206,199,0.15);color: #00c1bb">Patient Safety</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Introduction</h3> <p>Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.</p> <h3>Methods</h3> <p>We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.</p> <h3>Results</h3> <p>Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).</p> <h3>Conclusions</h3> <p>The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Gaps and priorities in innovation for children’s surgery.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37976896" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Fitzgerald TN</span>, <span>Zambeli-Ljepović A</span>, <span>Olatunji BT</span>, <span>Saleh A</span>, <span>Ameh EA</span></p> <div class="PublicationTile__description"><p><em>Seminars in pediatric surgery</em><br /> PubDate: 2023 Dec<br /> PUBMED: 37976896 ; DOI: 10.1016/j.sempedsurg.2023.151352 ; PII: S1055-8586(23)00099-9</p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p>Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children’s surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children’s surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children’s surgery worldwide.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/38019510" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Starr N</span>, <span>Gebeyehu N</span>, <span>Nofal MR</span>, <span>Forrester JA</span>, <span>Tesfaye A</span>, <span>Mammo TN</span>, <span>Weiser TG</span>, <span>and Lifebox Clean Cut Collaborative</span>, <span>Amdie DA</span>, <span>Abreha M</span>, <span>Alemu M</span>, <span>Ally S</span>, <span>Abdukadir AA</span>, <span>Assefa G</span>, <span>Bedore Y</span>, <span>Bekele A</span>, <span>Berhanu M</span>, <span>Alemu SB</span>, <span>Chimdesa Z</span>, <span>Derbew M</span>, <span>Fast C</span>, <span>Fernandez K</span>, <span>Kahsay S</span>, <span>Kassahun A</span>, <span>Kebede H</span>, <span>Kitesa G</span>, <span>Koritsanszky L</span>, <span>Lima B</span>, <span>Mellese B</span>, <span>Mengistu M</span>, <span>Negash S</span>, <span>Tara M</span>, <span>Taye S</span>, <span>Torgeson K</span>, <span>Tsehaye M</span>, <span>Tiruneh A</span>, <span>Stave K</span></p> <div class="PublicationTile__description"><p><em>JAMA surgery</em><br />PubDate: 2023 Nov 29<br /><span>PUBMED: 38019510</span> ; <span>DOI: 10.1001/jamasurg.2023.6033</span> ; <span>PII: 2812301</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Importance</h3> <p>Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support.</p> <h3>Objective</h3> <p>To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined.</p> <h3>Design, setting, and participants</h3> <p>This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls.</p> <h3>Exposure</h3> <p>Implementation of the refined Clean Cut program.</p> <h3>Main outcomes and measures</h3> <p>The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications.</p> <h3>Results</h3> <p>A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly.</p> <h3>Conclusions and relevance</h3> <p>A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Tracheostomy care quality improvement in low- and middle-income countries: A scoping review.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37943736" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Selekwa M</span>, <span>Maina I</span>, <span>Yeh T</span>, <span>Nkya A</span>, <span>Ncogoza I</span>, <span>Nuss RC</span>, <span>Mushi BP</span>, <span>Haddadi S</span>, <span>Van Loon K</span>, <span>Mbaga E</span>, <span>Massawe W</span>, <span>Roberson DW</span>, <span>Dharsee N</span>, <span>Musimu B</span>, <span>Xu MJ</span></p> <div class="PublicationTile__description"><p><em>PLOS global public health</em><br />PubDate: 2023<br /><span>PUBMED: 37943736</span> ; <span>PMC: PMC10635432</span> ; <span>DOI: 10.1371/journal.pgph.0002294</span> ; <span>PII: PGPH-D-23-01326</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p>Tracheostomy is a lifesaving, essential procedure performed for airway obstruction in the case of head and neck cancers, prolonged ventilator use, and for long-term pulmonary care. While successful quality improvement interventions in high-income countries such as through the Global Tracheostomy Collaborative significantly reduced length of hospital stay and decreased levels of anxiety among patients, limited literature exists regarding tracheostomy care and practices in low and middle-income countries (LMIC), where most of the world resides. Given limited literature, this scoping review aims to summarize published tracheostomy studies in LMICs and highlight areas in need of quality improvement and clinical research efforts. Based on the PRISMA guidelines, a scoping review of the literature was performed through MEDLINE/PubMed and Embase using terms related to tracheostomy, educational and quality improvement interventions, and LMICs. Publications from 2000-2022 in English were included. Eighteen publications representing 10 countries were included in the final analysis. Seven studies described baseline needs assessments, 3 development of training programs for caregivers, 6 trialed home-based or hospital-based interventions, and finally 2 articles discussed development of standardized protocols. Overall, studies highlighted the unique challenges to tracheostomy care in LMICs including language, literacy barriers, resource availability (running water and electricity in patient homes), and health system access (financial costs of travel and follow-up). There is currently limited published literature on tracheostomy quality improvement and care in LMICs. Opportunities to improve quality of care include increased efforts to measure complications and outcomes, implementing evidence-based interventions tailored to LMIC settings, and using an implementation science framework to study tracheostomy care in LMICs.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Capnography-An Essential Monitor, Everywhere: A Narrative Review.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37862392" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Wollner EA</span>, <span>Nourian MM</span>, <span>Bertille KK</span>, <span>Wake PB</span>, <span>Lipnick MS</span>, <span>Whitaker DK</span></p> <div class="PublicationTile__description"><p><em>Anesthesia and analgesia</em><br />PubDate: 2023 Nov 1<br /><span>PUBMED: 37862392</span> ; <span>DOI: 10.1213/ANE.0000000000006689</span> ; <span>PII: 00000539-202311000-00005</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> <li class="terms__single" style="background-color: rgb(103,42,178);color: #ffffff">Anesthesia</li> <li class="terms__single" style="background-color: rgba(0,122,81,0.15);color: #007059">Critical Care</li> <li class="terms__single" style="background-color: rgba(0,206,199,0.15);color: #00c1bb">Patient Safety</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p>Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography’s use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography’s use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography’s safety benefits to all patients, everywhere.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Investing in the Surgical Healthcare of Children in the First 8000 Days of Life.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37805925" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Seyi-Olajide JO</span>, <span>Ozgediz D</span>, <span>Ameh EA</span></p> <div class="PublicationTile__description"><p><em>World journal of surgery</em><br />PubDate: 2023 Oct 8<br /><span>PUBMED: 37805925</span> ; <span>DOI: 10.1007/s00268-023-07208-w</span> ; <span>PII: 10.1007/s00268-023-07208-w</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Editorial</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Defining the Surgical Trainee’s Role in Global Surgery.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37787409" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Boeck MA</span></p> <div class="PublicationTile__description"><p><em>Journal of the American College of Surgeons</em><br />PubDate: 2023 Oct 3<br /><span>PUBMED: 37787409</span> ; <span>DOI: 10.1097/XCS.0000000000000883</span> ; <span>PII: 00019464-990000000-00756</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(129,215,66,0.24);color: #81d742">Education</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">A Summary of Diversity in Anesthesiology Among Medical Students, Anesthesiology Residents, and Anesthesiology Faculty.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37712473" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Armaneous M</span>, <span>Boscardin CK</span>, <span>Earnest GE</span>, <span>Ehie O</span></p> <div class="PublicationTile__description"><p><em>Anesthesia and analgesia</em><br />PubDate: 2023 Oct 1<br /><span>PUBMED: 37712473</span> ; <span>DOI: 10.1213/ANE.0000000000006606</span> ; <span>PII: 00000539-202310000-00016</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(103,42,178);color: #ffffff">Anesthesia</li> <li class="terms__single" style="background-color: rgba(129,215,66,0.24);color: #81d742">Education</li> </ul> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Impact of Bowel Coverage and Resuscitation Protocol on Gastroschisis Mortality in Low-Income Countries: Experience and Lessons From Uganda.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37838617" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Nimanya SA</span>, <span>Stephens CQ</span>, <span>Yap A</span>, <span>Kisa P</span>, <span>Kakembo N</span>, <span>Wesonga A</span>, <span>Okello I</span>, <span>Naluyimbazi R</span>, <span>Mbwali F</span>, <span>Kayima P</span>, <span>Ssewanyana Y</span>, <span>Naik-Mathuria B</span>, <span>Ozgediz D</span>, <span>Sekabira J</span></p> <div class="PublicationTile__description"><p><em>Journal of pediatric surgery</em><br />PubDate: 2023 Sep 22<br /><span>PUBMED: 37838617</span> ; <span>DOI: 10.1016/j.jpedsurg.2023.09.015</span> ; <span>PII: S0022-3468(23)00552-3</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Background</h3> <p>Gastroschisis causes near complete mortality in low-income countries (LICs). This study seeks to understand the impact of bedside bowel reduction and silo placement, and protocolized resuscitation on gastroschisis outcomes in LICs.</p> <h3>Methods</h3> <p>We conducted a retrospective cohort study of gastroschisis patients at a tertiary referral center in Kampala, Uganda. Multiple approaches for bedside application of bowel coverage devices and delayed closure were used: sutured urine bags (2017-2018), improvised silos using wound protectors (2020-2021), and spring-loaded silos (2022). Total parental nutrition (TPN) was not available; however, with the use of improvised silos, a protocol was implemented to include protocolized resuscitation and early enteral feeding. Risk ratios (RR) for mortality were calculated in comparison to historic controls from 2014.</p> <h3>Results</h3> <p>368 patients were included: 42 historic controls, 7 primary closures, 81 sutured urine bags, 133 improvised silos and 105 spring-loaded silos. No differences were found in sex (p = 0.31), days to presentation (p = 0.84), and distance traveled to the tertiary hospital (p = 0.16). Following the introduction of bowel coverage methods, the proportion of infants that survived to discharge increased from 2% to 16-29%. In comparison to historic controls, the risk of mortality significantly decreased: sutured urine bags 0.65 (95%CI: 0.52-0.80), improvised silo 0.76 (0.66-0.87), and spring-loaded silo 0.65 (0.56-0.76).</p> <h3>Conclusion</h3> <p>Bedside application of bowel coverage and protocolization decreases the risk of death for infants with gastroschisis, even in the absence of TPN. Further efforts to expand supply of low-cost silos in LICs would significantly decrease the mortality associated with gastroschisis in this setting.</p> <h3>Type of study</h3> <p>Treatment Study.</p> <h3>Level of evidence</h3> <p>III (Retrospective Comparative Study).</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">The Creation of a Pediatric Surgical Checklist for Adult Providers.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37790469" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Rapolti D</span>, <span>Kisa P</span>, <span>Situma M</span>, <span>Nico E</span>, <span>Lobe T</span>, <span>Sims T</span>, <span>Ozgediz D</span>, <span>Klazura G</span></p> <div class="PublicationTile__description"><p><em>Research square</em><br />PubDate: 2023 Sep 13<br /><span>PUBMED: 37790469</span> ; <span>PMC: PMC10543282</span> ; <span>DOI: 10.21203/rs.3.rs-3269257/v1</span> ; <span>PII: rs.3.rs-3269257</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single" style="background-color: rgba(0,206,199,0.15);color: #00c1bb">Patient Safety</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Purpose</h3> <p>To address the need for a pediatric surgical checklist for adult providers.</p> <h3>Background</h3> <p>Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications.</p> <h3>Methods</h3> <p>Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias.</p> <h3>Results</h3> <p>42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies.</p> <h3>Conclusion</h3> <p>The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes.</p> <h3>Funding</h3> <p>Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Confronting new challenges: Faculty perceptions of gaps in current laparoscopic curricula in a changing training landscape.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37731731" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Charondo LB</span>, <span>Brian R</span>, <span>Syed S</span>, <span>Chern H</span>, <span>Lager J</span>, <span>Alseidi A</span>, <span>O'Sullivan P</span>, <span>Bayne D</span></p> <div class="PublicationTile__description"><p><em>Surgery open science</em><br />PubDate: 2023 Dec<br /><span>PUBMED: 37731731</span> ; <span>PMC: PMC10507640</span> ; <span>DOI: 10.1016/j.sopen.2023.09.006</span> ; <span>PII: S2589-8450(23)00070-2</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(129,215,66,0.24);color: #81d742">Education</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgb(113,0,226);color: #ffffff">Urology</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Background</h3> <p>Opportunities for residents to develop laparoscopic skills have decreased with the rise in robotic operations and the development of complex, subspecialized laparoscopic operations. Given the changing training landscape, this study aimed to identify laparoscopic surgeons’ perceptions of gaps in current laparoscopic skills in general surgery, obstetrics-gynecology, and urology residency programs.</p> <h3>Methods</h3> <p>Laparoscopic surgeons who operate with residents participated in semi-structured interviews. Questions addressed expectations for resident proficiency, deficits in laparoscopic surgical skills, and barriers to learning and teaching. Two authors independently coded de-identified transcripts followed by a conventional content analysis.</p> <h3>Results</h3> <p>Fourteen faculty members from thirteen subspecialties participated. Faculty identified three main areas to improve laparoscopic training across specialties: foundational knowledge, technical skills, and cognitive skills. They also recognized an overarching opportunity to address faculty development.</p> <h3>Conclusions</h3> <p>This qualitative study highlighted key deficiencies in laparoscopic training that have emerged in the current, changing era of minimally invasive surgery.</p> <h3>Key message</h3> <p>This qualitative study identified laparoscopic educators’ perceptions of deficiencies in laparoscopic training. Findings emphasized the importance of incorporating high quality educational practices to optimize training in the current changing landscape of laparoscopic surgery.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37385869" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Yap A</span>, <span>Olatunji BT</span>, <span>Negash S</span>, <span>Mweru D</span>, <span>Kisembo S</span>, <span>Masumbuko F</span>, <span>Ameh EA</span>, <span>Lebbie A</span>, <span>Bvulani B</span>, <span>Hansen E</span>, <span>Philipo GS</span>, <span>Carroll M</span>, <span>Hsu PJ</span>, <span>Bryce E</span>, <span>Cheung M</span>, <span>Fedatto M</span>, <span>Laverde R</span>, <span>Ozgediz D</span></p> <div class="PublicationTile__description"><p><em>Surgery</em><br />PubDate: 2023 Sep<br /><span>PUBMED: 37385869</span> ; <span>DOI: 10.1016/j.surg.2023.05.010</span> ; <span>PII: S0039-6060(23)00305-7</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(68,132,0,0.23);color: #4c8728">Advocacy</li> <li class="terms__single" style="background-color: rgba(185,0,198,0.15);color: #ef00d7">Pediatrics</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Background</h3> <p>Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient.</p> <h3>Methods</h3> <p>A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child’s surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure.</p> <h3>Results</h3> <p>In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child’s surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002).</p> <h3>Conclusion</h3> <p>A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">The Global Otolaryngology-Head and Neck Surgery Workforce.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37651133" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Petrucci B</span>, <span>Okerosi S</span>, <span>Patterson RH</span>, <span>Hobday SB</span>, <span>Salano V</span>, <span>Waterworth CJ</span>, <span>Brody RM</span>, <span>Sprow H</span>, <span>Alkire BC</span>, <span>Fagan JJ</span>, <span>Tamir SO</span>, <span>Der C</span>, <span>Bhutta MF</span>, <span>Maina IW</span>, <span>Pang JC</span>, <span>Daudu D</span>, <span>Mukuzi AG</span>, <span>Srinivasan T</span>, <span>Pietrobon CA</span>, <span>Hao SP</span>, <span>Nakku D</span>, <span>Seguya A</span>, <span>Din TF</span>, <span>Mbougo OD</span>, <span>Mokoh LW</span>, <span>Jashek-Ahmed F</span>, <span>Law TJ</span>, <span>Holt EA</span>, <span>Bangesh AH</span>, <span>Zemene Y</span>, <span>Ibekwe TS</span>, <span>Diallo OR</span>, <span>Alvarado J</span>, <span>Mulwafu WK</span>, <span>Fenton JE</span>, <span>Agius AM</span>, <span>Doležal P</span>, <span>Mudekereza ÉA</span>, <span>Mojica KM</span>, <span>Rueda RS</span>, <span>Xu MJ</span></p> <div class="PublicationTile__description"><p><em>JAMA otolaryngology– head & neck surgery</em><br />PubDate: 2023 Aug 31<br /><span>PUBMED: 37651133</span> ; <span>PMC: PMC10472262</span> ; <span>DOI: 10.1001/jamaoto.2023.2339</span> ; <span>PII: 2808978</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(136,45,226,0.28);color: #8224e3">OHNS</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> <li class="terms__single" style="background-color: rgba(65,0,229,0.15);color: #0b00e5">Workforce</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><h3>Importance</h3> <p>A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed.</p> <h3>Objective</h3> <p>To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories.</p> <h3>Design, setting, and participants</h3> <p>A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians.</p> <h3>Main outcome</h3> <p>The OHNS workforce per capita, stratified by income and region.</p> <h3>Results</h3> <p>Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world’s population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally.</p> <h3>Conclusion and relevance</h3> <p>This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">From a Chicken Model to a Patient: Microsurgical Repair of a Brachial Artery in Mozambique.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37636328" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Santos P</span>, <span>Gonzalez M</span>, <span>Davis GL</span>, <span>Pusic AL</span>, <span>Rohde CH</span></p> <div class="PublicationTile__description"><p><em>Plastic and reconstructive surgery. Global open</em><br />PubDate: 2023 Aug<br /><span>PUBMED: 37636328</span> ; <span>PMC: PMC10448937</span> ; <span>DOI: 10.1097/GOX.0000000000005216</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single" style="background-color: rgb(247,98,24);color: #ffffff">CHESA Fellows</li> <li class="terms__single" style="background-color: rgb(0,124,190);color: #ffffff">Surgery</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p>In sub-Saharan Africa, options for reconstruction of traumatic injuries are limited due to lack of access to microsurgery-trained surgeons. Recently, the Plastic Surgery Foundation-sponsored Surgeons in Humanitarian Alliance for Reconstruction, Research and Education group hosted a virtual microsurgery skills course for junior plastic surgeons in this region. In this report, we describe a case of complete brachial artery transection requiring microsurgical techniques and use of vein graft for repair at our provincial hospital in Mozambique. By highlighting this case, we aimed to describe a direct clinical application of the Surgeons in Humanitarian Alliance for Reconstruction, Research and Education virtual microsurgery skills course and to demonstrate the profound impact such courses can have on patient outcomes in low-and middle-income countries with limited or no access to microsurgery-trained surgeons. Further, through newly gained familiarity with standard microsurgery instruments used in reconstructive procedures, we were able to improvise and develop modified instruments to overcome lack of resources at our institution.</p> </div> </div> </div> <div class="PublicationTile"> <div class="PublicationTile__header"> <h2 class="header__title">Health Disparity Curricula for Ophthalmology Residents: Current Landscape, Barriers, and Needs.</h2> <a href="https://pubmed.ncbi.nlm.nih.gov/37564161" title="Open publication - link opens in new tab" target="_blank" class="header__link"> <span>Open publication</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/icon-target-blank-blue.svg" alt="icon-target-blank-blue"/> </a> </div> <p class="PublicationTile__authors"><span>Carvajal N</span>, <span>Lopez J</span>, <span>Ahmad TR</span>, <span>Maru J</span>, <span>Ramanathan S</span>, <span>Seitzman GD</span>, <span>Padmanabhan S</span>, <span>Parikh N</span></p> <div class="PublicationTile__description"><p><em>Journal of academic ophthalmology (2017)</em><br />PubDate: 2023 Jul<br /><span>PUBMED: 37564161</span> ; <span>PMC: PMC10411222</span> ; <span>DOI: 10.1055/s-0043-1771356</span> ; <span>PII: JAO-427</span></p> </div> <div class="PublicationTile__row"> <ul class="row__terms"> <li class="terms__single">Journal Article</li> <li class="terms__single" style="background-color: rgba(129,215,66,0.24);color: #81d742">Education</li> <li class="terms__single" style="background-color: rgba(216,115,0,0.15);color: #c46200">Ophthalmology</li> </ul> <button class="row__button" aria-label="Show abstract"> <span>Show abstract</span> <span>Hide abstract</span> <img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/chevron-down-black.svg" alt="chevron-down-black"/> </button> </div> <div class="PublicationTile__wrapper"> <div class="wrapper__abstract"><p> Social determinants of health play a critical role in visual health outcomes. Yet, there exists no structured curriculum for ophthalmology residents to identify and address health disparities relevant to eye care or no a standard assessment of health disparities education within ophthalmology residency programs. This study aims to characterize current health disparity curricula in ophthalmology residency programs in the United States, determine resident confidence in addressing health disparities in the clinical setting, and identify perceived barriers and needs of program directors (PDs) and residents in this area. This was a cross-sectional survey study. A closed-ended questionnaire with comments was distributed to the Accreditation Council for Graduate Medical Education-accredited ophthalmology residency PDs and residents in April 2021 and May 2022. The questionnaire solicited characteristics of any existing health disparity curricula, PD and resident perceptions of these curricula, and residents’ experience with and confidence in addressing health disparities in the delivery of patient care. In total, 29 PDs and 96 residents responded. Sixty-six percent of PDs stated their program had a formal curriculum compared to fifty-three percent of residents. Forty-one percent of PDs and forty-one percent of residents stated their program places residents in underserved care settings for more than 50% of their training. Most residents (72%) were confident in recognizing health disparities. Sixty-six percent were confident in managing care in the face of disparities and fifty-nine percent felt they know how to utilize available resources. Residents were most concerned with the lack of access to resources to help patients. Forty-five percent of PDs felt the amount of time dedicated to health disparities education was adequate. Forty-nine percent of residents reported they felt the amount of training they received on health disparities to be adequate. The top barrier to curriculum development identified by PDs was the availability of trained faculty to teach. Time in the curriculum was a major barrier identified by residents. Roughly half of ophthalmology residency programs who responded had a health disparity curriculum; however, both PDs and residents felt inadequate time is dedicated to such education. National guidance on structured health disparity curricula for ophthalmology residents may be warranted as a next step.</p> </div> </div> </div> </div> <div class="Pagination"> <div class="Pagination__button Pagination__button--prev"><img src="https://globalsurgery.org/wp-content/themes/global-surgery/assets/svg/border-arrow-white.svg" alt="border-arrow-white"/></div> <p>1</p> <a href="https://globalsurgery.org/publications/?page_num=2"title="Go to page number 2" class="Pagination__item">2</a> <a href="https://globalsurgery.org/publications/?page_num=3"title="Go to page number 3" class="Pagination__item">3</a> <a href="https://globalsurgery.org/publications/?page_num=4"title="Go to page number 4" class="Pagination__item">4</a> <a href="https://globalsurgery.org/publications/?page_num=5"title="Go to page number 5" class="Pagination__item">5</a> <a href="https://globalsurgery.org/publications/?page_num=6"title="Go to page number 6" class="Pagination__item">6</a> <a 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