Surgery In Low- And Middle-income Countries Research Articles

Morbidity and Mortality Following Surgery for Pancreatic Cancer in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Measuring postoperative outcomes after complex cancer operations such as pancreatectomy is vital to improve cancer surgery in low- and middle-income countries (LMICs); however, such data is often limited. This study aimed to review existing research and obtain baseline estimates for postoperative mortality and morbidity after pancreatic cancer surgery in LMICs. PubMed, Embase, Web of Science Core Collection, and Global Index Medicus were systematically searched for original articles published between January 2005 and May 2022. LMICs based studies reporting postoperative mortality, morbidity, and/or length of stay of patients with primary pancreatic tumors undergoing pancreaticoduodenectomy and/or distal pancreatectomy were included. Of 18 344 unique titles and abstracts retrieved, 114 studies met the inclusion criteria. Of these, 51 "good" quality studies comprising 7528 patients were included in the meta-analyses. Pooled estimates for pancreatic fistula were 16.6% (95% CI 14.0-19.7, p < 0.001); 16.0% (95% CI 11.1-22.5, p < 0.001) for Clavien-Dindo grade 3 and 4 complications; 13.4% (95% CI 9.8-17.9, p < 0.001) for wound infection; and 4.4% (95% CI 3.3-5.7, p < 0.001) for postoperative mortality. This is the first systematic review and meta-analysis examining surgical complications after pancreatic surgery in LMICs. We highlight a lack of data and the need to further evaluate surgical outcomes in LMICs.

Association between self-reported visual symptoms (suggesting cataract) and self-reported fall-related injury among adults aged ≥ 65 years from five low- and middle-income countries.

Cataracts may increase risk for falls but studies on this topic from low- and middle-income countries (LMICs) are scarce. Therefore, we examined the cross-sectional association between self-reported visual symptoms (suggesting cataract) and self-reported injurious falls in nationally representative samples of adults aged ≥ 65 years from five LMICs (China, Ghana, India, Mexico, and Russia). Data from the WHO Study on global AGEing and adult health (SAGE) were analysed. Self-reported information on past 12-month fall-related injury and cataract based on symptoms were collected. Multivariable logistic regression and meta-analyses were conducted to assess associations. Data on 13,101 people aged ≥ 65 years were analysed [mean (SD) age 72.5 (11.3) years; 45.2% males]. The overall prevalence of self-reported fall-related injury and visual symptoms (suggesting cataract) were 4.9% and 29.4%, respectively. There was a positive association between self-reported visual symptoms (suggesting cataract) and fall-related injury (i.e., OR > 1) in all five countries but statistical significance was reached in three: China (OR = 1.60; 95% CI = 1.08-2.35), India (OR = 1.96; 95% CI = 1.15-3.35), and Russia (OR = 3.58; 95% CI = 2.06-6.24). The pooled OR including all five countries based on a meta-analysis was OR = 1.88 (95% CI = 1.32-2.68). Self-reported visual symptoms (suggesting cataract) were associated with higher odds for self-reported injurious falls among older adults in LMICs. Expanding availability of cataract surgery in LMICs may also have the additional benefit of reducing falls among older people.

First experience in laparoscopic surgery in low and middle income countries: A systematic review.

Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers. To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources. MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery. Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors. Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.

312 First Experience in Laparoscopic Surgery in Low- and Middle-Income Countries: A Systematic Review

Abstract Aim This study aims to report the challenges and benefits of introducing laparoscopic surgery in low-and-middle-income countries (LMIC) as well as to identify solutions to these challenges for countries with limited finances and resources. Method MEDLINE, EMBASE and COCHRANE databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published after 1996 with full text available in English. Exclusion criteria were studies considering only open surgery, ENT, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery. Results Ten studies from eight LMIC were eligible for inclusion in the final analysis, totalling 2640 patients. Most reported challenges were related to costs, including affordability of equipment and training programmes, and equipment problems such as faulty equipment and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including reduced hospital stay, complications and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors. Conclusions Despite initial challenges, many studies described the benefits of introducing laparoscopic surgery. Centres proposed practical solutions to these challenges to ensure the sustainability of laparoscopic surgery in LMIC.

Malnutrition and nutritional screening in patients undergoing surgery in low and middle income countries: A systematic review

AbstractBackgroundThere is a high incidence of preoperative undernutrition in hospitalised patients in low and middle‐income countries (LMICs), leading to increased postoperative complications, length of hospital stay and early mortality. Review aims are to establish the prevalence of undernutrition and assess the use of validated nutritional screening tools in surgical patients across LMICs.MethodsProtocol was PRISMA compliant and Prospero registered (CRD42019126765). Twelve international databases were searched from January 1990 to April 2021. Included studies were on nutritional screening in adults (≥16 years) undergoing surgery in LMICs. Two researchers screened studies and assessed quality. Prevalence of undernutrition was presented as a weighted percentage with confidence intervals (CI).ResultsOf the 4649 records identified, 16 studies (n = 4032) were eligible. Subjective global assessment (SGA) or patient generated (PG)‐SGA were the tools used most widely. SGA and PG‐SGA showed a high prevalence of undernutrition overall (0.61, 95% CI 0.50, 0.73), with a proportion identified with moderate undernutrition (0.44, 95% CI 0.31, 0.57) or severe undernutrition (0.32, 95% CI 0.19, 0.45).ConclusionsData show the prevalence of undernutrition in surgical patients as high as three in five patients within LMICs. Results indicate that the SGA is suitable for assessing this group of patients and that it may be the most appropriate tool to use due to its subjectivity and reliability. PG‐SGA although similar includes more symptom assessment, which is important for nutritionally depleted cancer patients. The limited data on validity and reliability of nutritional screening tools in LMICs indicates further research is required.

The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis

Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46–0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40–0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26–0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect −0.14, −0.22 to −0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (−0.13, −0.22 to −0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.

Prevalence of Critical Congenital Heart Disease During Surgical Mission Trips to Low-Middle Income Countries. What to Expect

Background&#x0D; The incidence of congenital heart disease (CHD) is about 8 per 1000 live births. About 20% of those patients diagnosed with CHD will present early after birth with Critical Congenital Heart Disease (CCHD) necessitating a catheter or surgical intervention during the neonatal period. This is based on Western literature and Western countries. Little is known about the actual prevalence of CCHD at the time of clinical assessment and treatment during surgical missions in low and middle income countries (LMICs).&#x0D; Methods&#x0D; This is a retrospective study and it compares prevalence of CCHD at time of presentation for surgery in LMICs&#x0D; to published data for similar cohorts in the USA. We discuss potential causes for epidemiological discrepancies&#x0D; Proportions were compared using OR and 95% CI. Significance was set at p&lt;0.01. We chose to classify our patients considering the number of ventricles (1or 2) combined with the existence of Aortic Arch obstruction (Yes/No) resulting in a CCHD classification with 4 categories&#x0D; Results&#x0D; Between Feb 2008 - June 2019 we operated 6115 patients in 27 countries. Of those, 243 Neonates were presented to our cardiologists&#x0D; after excluding simple PDA ligations in Preterm newborns and 239 neonates were surgically treated for their CCHD&#x0D; (4% of the total). overall surgical mortality among the 243 neonates operated in LMIC for their CCHD was 19.7% (n=48). Main discrepancies were in Classes 1 represented by 63% of our treated CCHD (p&lt;.0001) while Class 4 neonates represented only 4.2% of our total (p&lt;.0001). When compared to Western prevalence, Transposition of the Great Arteries was over-represented while some cyanotic (ToF) and non-cyanotic diagnosis (Critical Aortic Stenosis) were under-represented.&#x0D; Conclusions&#x0D; Patients diagnosed and treated for CCHD in LMICs during humanitarian missions represent but a very small fraction of the total number of patients born with CCHD in those countries. &#x0D; Discrepancies in specific diagnoses and prevalence between LMIC and their high-income counterparts are likely multifactorial, and management should be adapted to the conditions of each country and health system.&#x0D; Proper prenatal diagnosis, specialized critical neonatal transportation systems, countrywide availability of Prostaglandins and at least one highly functioning heart center are some of the most basic needs required in order to revert the current natural history of CCHD in countries with limited resources settings.

Impact of the COVID-19 Pandemic on Pediatric Surgical Volume in Four Low- and Middle-Income Country Hospitals: Insights from an Interrupted Time Series Analysis

BackgroundThe impact of the COVID-19 pandemic on surgical care delivery in low- and middle-income countries (LMIC) has been challenging to assess due to a lack of data. This study examines the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals.MethodsRetrospective and prospective pediatric surgical data collected at hospitals in Burkina Faso, Ecuador, Nigeria, and Zambia were reviewed from January 2019 to April 2021. Changes in surgical volume were assessed using interrupted time series analysis.Results6078 total operations were assessed. Before the pandemic, overall surgical volume increased by 21 cases/month (95% CI 14 to 28, p < 0.001). From March to April 2020, the total surgical volume dropped by 32%, or 110 cases (95% CI − 196 to − 24, p = 0.014). Patients during the pandemic were younger (2.7 vs. 3.3 years, p < 0.001) and healthier (ASA I 69% vs. 66%, p = 0.003). Additionally, they experienced lower rates of post-operative sepsis (0.3% vs 1.5%, p < 0.001), surgical site infections (1.3% vs 5.8%, p < 0.001), and mortality (1.6% vs 3.1%, p < 0.001).ConclusionsDuring the COVID-19 pandemic, children’s surgery in LMIC saw a sharp decline in total surgical volume by a third in the month following March 2020, followed by a slow recovery afterward. Patients were healthier with better post-operative outcomes during the pandemic, implying a widening disparity gap in surgical access and exacerbating challenges in addressing the large unmet burden of pediatric surgical disease in LMICs with a need for immediate mitigation strategies.

165 Cataract Surgery: What Intraoperative Factors Impact Surgical Outcomes in Low- and Middle- Income Countries (LMICs)

Abstract Aim To describe what intraoperative factors affect the outcomes of cataract surgery in LMICs. Method The following databases were screened to find relevant articles: EMBASE (1974–2019), MEDLINE (1946–2019), Global health (1973–2019), PubMed, Cochrane library and Cumulative Index to Nursing and Allied Health Literature. Following this, duplicates were removed, and articles underwent screening. Results Perioperative checks – It has been recommended for LMICs to implement similar surgical checklists to what is used in the UK, to reduce the chance of surgical complications. Having the right team - The cataract surgery team may vary in different countries. For example, in Ethiopia the staffing model includes ophthalmologists, non-physician cataract surgeons (NPCS), ophthalmic officers, ophthalmic nurses, operating room nurses and integrated eye care workers. It is common in LMICs for NPCS to outnumber ophthalmologists. Adequately skilled professionals – It’s important to consider having vitreoretinal surgical input available should surgical complications arise. This will help to optimise outcomes. Surgical technique – Techniques performed in LMICs include ICCE (intracapsular cataract extraction), ECCE (extracapsular cataract extraction and MSICS (manual small incision surgery) and phacoemulsification. ECCE and MSICS is the most commonly used in LMICS due to comparable outcomes with phacoemulsification and cost effectiveness. Surgical training and skills transfer – Various international training programmes such as the HelpMeSee programme is designed to help train ophthalmologists and NPCS in MSICS via simulation. Conclusions The above factors are important considerations which influence surgical availability and success. LMICs have an increasingly aging population and cataract services will be required to adapt to the increase demand.

Impact of COVID-19 on Elective Cleft Surgery in Low- and Middle-income Countries.

Background:The COVID-19 pandemic disrupted health systems worldwide, including in low- and middle-income countries (LMICs). Many countries limited the delivery of elective surgery. To date, COVID-19’s impact on elective surgery in LMICs has been unquantified. We use operative data from a large international non-government cleft organization to compare case volume for 2019 and 2020 to quantify the impact of COVID-19.Methods:Smile Train supports a partner network of over 1100 partners globally to deliver treatment to children with cleft lip and cleft palate (CLP). Treatment data is documented into a proprietary digital platform, Smile Train Express. We compared monthly treatment data for 2019 to 2020, by country, and by World Bank Income group to describe the effect that the COVID-19 pandemic has had on CLP surgery in LMICs.Results:Our analysis shows 25,444 (31.4%) fewer primary operations performed between January and December 2020 than in the same period in 2019 with the most significant decline in procedures observed in April 2020. Many countries resumed elective surgery for CLP procedures from May onward and volume approximated that of pre-pandemic baseline by November of 2020.Conclusions:The emergence of the COVID-19 pandemic had a large impact on health systems and service delivery across the world. We find that this is evident in the delivery of CLP surgery in LMICs. The impact is characterized by a dramatic decrease in surgery rates in April of 2020 with a recovery of surgical volume from July 2020 onwards. The rate of surgical rate recovery is consistent across World Bank Income groups.

Canadian surgeon and resident involvement in international plastic surgery.

SummarySurgery has become increasingly recognized as an important component of health care in low and middle income countries (LMICs). Many surgeons from high income countries (HICs) are interested in working on improving access to surgery in LMICs. We sought to evaluate the involvement and potential barriers of Canadian plastic surgeons and plastic surgery residents in international work with an online survey. The survey indicated that plastic surgery residents have a high interest and involvement in international electives, with 45% of graduating residents previously involved. About 40% of respondents were involved in international projects, and academic plastic surgeons were more frequently involved than community surgeons. Taking time off work and personal/family commitments were cited as the greatest obstacles for those who are currently involved, whereas finding opportunities was the biggest challenge for those who would like to participate in the future.

Forward Surgical Teams as a Model for Humanitarian Orthopedic Surgical Care: A Review of Current Literature.

Orthopedic trauma is a significant portion of global burden of disease in low- and middle-income countries (LMICs). This has led the World Health Organization to advocate for increased surgical intervention in LMICs. The two largest barriers to orthopedic surgical care for LMICs are cost of procedure and geographic access to centers with appropriate surgical capabilities. There is no current consensus on how to structure surgical interventional teams. The overall objective of this study is to describe the composition of a forward surgical team (FST), including its abilities and limitations. It is hypothesized that an FST is an effective model for orthopedic surgical relief efforts in LMICs. A narrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards published by the National Academies of Medicine. Studies were evaluated by structured review procedures to identify an FST's capacity for orthopedic surgery, as well as applicability for humanitarian care. Articles detailing FST logistics, types of orthopedic treatment provided, and instances of humanitarian care while deployed in austere environments were included for review. The FST is a military surgical unit operating with a small crew of surgeons and supporting staff who use tents or trailers that can be positioned near points of conflict, often in remote or austere environments. FSTs were designed to treat traumatic injuries, including orthopedic trauma from RTIs. If used as a sponsored humanitarian aid mission, FSTs can provide surgical care at free or greatly reduced costs. Because FSTs carry limited supplies and personnel, they are highly mobile surgical units that can be transported via truck. FSTs are effective models for humanitarian orthopedic surgery in LMICs. FSTs were designed to treat orthopedic trauma, the largest burden of orthopedic care in LMICs. Efficient use of limited equipment allows FSTs to be cost effective for funding sources and highly mobile to reduce the geographic barrier to care. Further research is needed to determine the cost to operate an FST and ethical consideration for military intervention for foreign humanitarian aid.

Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review.

Laparoscopic surgery has the potential to improve care in resource-deprived low- and-middle-income countries (LMICs). This study aims to analyse the barriers to training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two researchers screened results with mutual agreement. Included papers were in English, focused on abdominal laparoscopy and training in LMICs. PRISMA guidelines were followed; 2992 records were screened, and 86 full-text articles reviewed to give 26 key papers. Thematic grouping identified seven key barriers: funding; availability and maintenance of equipment; local access to experienced laparoscopic trainers; stakeholder dynamics; lack of knowledge on effective training curricula; surgical departmental structure and practical opportunities for trainees. In low-resource settings, technological advances may offer low-cost solutions in the successful implementation of laparoscopic training and improve access to surgical care.

An Accessible Laparoscope for Surgery in Low- and Middle- Income Countries.

Laparoscopic surgery is the standard of care in high-income countries for many procedures in the chest and abdomen. It avoids large incisions by using a tiny camera and fine instruments manipulated through keyhole incisions, but it is generally unavailable in low- and middle-income countries (LMICs) due to the high cost of installment, lack of qualified maintenance personnel, unreliable electricity, and shortage of consumable items. Patients in LMICs would benefit from laparoscopic surgery, as advantages include decreased pain, improved recovery time, fewer wound infections, and shorter hospital stays. To address this need, we developed an accessible laparoscopic system, called the ReadyView laparoscope for use in LMICs. The device includes an integrated camera and LED light source that can be displayed on any monitor. The ReadyView laparoscope was evaluated with standard optical imaging targets to determine its performance against a state-of-the-art commercial laparoscope. The ReadyView laparoscope has a comparable resolving power, lens distortion, field of view, depth of field, and color reproduction accuracy to a commercially available endoscope, particularly at shorter, commonly-used working distances (3-5cm). Additionally, the ReadyView has a cooler temperature profile, decreasing the risk for tissue injury and operating room fires. The ReadyView features a waterproof design, enabling sterilization by submersion, as commonly performed in LMICs. A custom desktop software was developed to view the video on a laptop computer with a frame rate greater than 30 frames per second and to white balance the image, which is critical for clinical use. The ReadyView laparoscope is capable of providing the image quality and overall performance needed for laparoscopic surgery. This portable low-cost system is well suited to increase access to laparoscopic surgery in LMICs.

Predicting the Impact of Neurosurgery on TBI Patients in the Low Resource Setting

Abstract INTRODUCTION Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these low-resource settings, effective triage of TBI patients-including the decision of whether or not to perform neurosurgery-is critical in optimizing both patient outcomes and healthcare resource utilization. METHODS Data from TBI patients of all ages were prospectively collected at Mulago National Referral Hospital in Kampala, Uganda, from 2016 to 2019. Seven different machine learning models (based on 1 linear and 6 non-linear algorithms) designed to predict good vs poor outcome near hospital discharge were developed and internally validated using 5-fold cross-validation. Predictors included clinical variables easily acquired on admission-demographics, physical exam, and mechanism of injury-and whether or not the patient received surgery. Using the elastic-net regularized logistic regression model (GLMnet), the probability of poor outcome was calculated for each patient both with and without surgery (quantifying the “treatment benefit”). A relative treatment benefit was then calculated, equaling this benefit of surgery divided by the probability of bad outcome with no surgery. Predictions were calibrated using Platt scaling. RESULTS Ultimately, 1766 patients were included. Areas under the receiver operating characteristic curve (AUCs) ranged from 81.7% (k-nearest neighbors) to 88.0% (random forest). The GLMnet had the second-best AUC at 87.7%. For the entire cohort, the median relative treatment benefit was 37.6% (IQR, 31.0% to 46.0%); similarly, in just those receiving surgery, it was 38.0% (IQR, 31.4% to 47.0%). The top four variables promoting good outcomes in the GLMnet model were high GCS, being fully alert, having both pupils reactive, and receiving surgery. CONCLUSION We provide the first deployable machine learning-based model to predict TBI outcomes with and without surgery in LMICs, thus enabling more effective surgical decision making in the resource-limited setting. Currently, patients are not being optimally chosen for neurosurgical intervention. Future studies should externally validate the model, improve model performance by combining data across countries, and explore use of more advanced algorithms.

Task Sharing in Global Anesthesia and Surgery: Workforce Concerns

This review highlights the role of task sharing in temporarily solving the human resource crisis in anesthesia and surgery in low- and middle-income countries (LMICs) while emphasizing the need for these countries to increase the workforce of anesthesiologists and surgeons as a permanent solution. Despite the obvious need for specialists to provide safe anesthesia and surgery in the LMICs, there is still a critical shortage of skilled personnel to fill this gap. Task sharing and task shifting are temporary solutions to this crisis but continue to be a challenge. Even with such measures in place, the current specialist workforce density is a far cry from the recommended safe anesthesia and surgical workforce density. Task sharing is crucial to the future of anesthesia and surgery in LMICs, but it must be balanced with quality patient care. Upscaling of the current specialized surgical workforce in LMICs must be both qualitative and quantitative.

Predicting the Individual Treatment Effect of Neurosurgery for Patients with Traumatic Brain Injury in the Low-Resource Setting: A Machine Learning Approach in Uganda.

Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these low-resource settings, effective triage of patients with TBI-including the decision of whether or not to perform neurosurgery-is critical in optimizing patient outcomes and healthcare resource utilization. Machine learning may allow for effective predictions of patient outcomes both with and without surgery. Data from patients with TBI was collected prospectively at Mulago National Referral Hospital in Kampala, Uganda, from 2016 to 2019. One linear and six non-linear machine learning models were designed to predict good versus poor outcome near hospital discharge and internally validated using nested five-fold cross-validation. The 13 predictors included clinical variables easily acquired on admission and whether or not the patient received surgery. Using an elastic-net regularized logistic regression model (GLMnet), with predictions calibrated using Platt scaling, the probability of poor outcome was calculated for each patient both with and without surgery (with the difference quantifying the "individual treatment effect," ITE). Relative ITE represents the percent reduction in chance of poor outcome, equaling this ITE divided by the probability of poor outcome with no surgery. Ultimately, 1766 patients were included. Areas under the receiver operating characteristic curve (AUROCs) ranged from 83.1% (single C5.0 ruleset) to 88.5% (random forest), with the GLMnet at 87.5%. The two variables promoting good outcomes in the GLMnet model were high Glasgow Coma Scale score and receiving surgery. For the subgroup not receiving surgery, the median relative ITE was 42.9% (interquartile range [IQR], 32.7% to 53.5%); similarly, in those receiving surgery, it was 43.2% (IQR, 32.9% to 54.3%). We provide the first machine learning-based model to predict TBI outcomes with and without surgery in LMICs, thus enabling more effective surgical decision making in the resource-limited setting. Predicted ITE similarity between surgical and non-surgical groups suggests that, currently, patients are not being chosen optimally for neurosurgical intervention. Our clinical decision aid has the potential to improve outcomes.

Financial Risk Protection and Hospital Admission for Trauma in Cameroon: An Analysis of the Cameroon National Trauma Registry.

Half of the global population is at risk for catastrophic health expenditure (CHE) in the event that they require surgery. Universal health coverage fundamentally requires protection from CHE, particularly in low- and middle-income countries (LMICs). Financial risk protection reports in LMICs covering surgical care are limited. We explored the relationship between financial risk protection and hospital admission among injured patients in Cameroon to understand the role of health insurance in addressing unmet need for surgery in LMICs. The Cameroon National Trauma Registry, a database of all injured patients presenting to the emergency departments (ED) of three Cameroonian hospitals, was retrospectively reviewed between 2015 and 2017. Multivariate regression analysis identified predictors of hospital admission after injury and of patient report of cost inhibiting their care. Of the 7603 injured patients, 95.7% paid out-of-pocket to finance ED care. Less than two percent (1.42%) utilized private insurance, and more than half (54.7%) reported that cost inhibited their care. In multivariate analysis, private insurance coverage was a predictor of hospital admission (OR 2.17, 95% CI: 1.26, 3.74) and decreased likelihood of cost inhibiting care (OR 0.34, 95% CI: 0.20, 0.60) when compared to individuals paying out-of-pocket. The prevalence of out-of-pocket spending among injured patients in Cameroon highlights the need for financial risk protection that encompasses surgical care. Patients with private insurance were more likely to be admitted to the hospital, and less likely to report that cost inhibited care, supporting private health insurance as a potential financing strategy.

Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda.

Background: Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. Methods: A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Results: Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. Conclusion: There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.

Pediatric Cardiac Surgery in Low-and Middle-Income Countries: Present Status and Need for a Paradigm Shift.

In low and mid-income countries, there has been a 50% global decrease in the incidence of preventable deaths of children since 1990. However, the mortality from non-communicable diseases (NCD) such as congenital heart disease (CHD) has not changed. Of the estimated 1.3 million children born with CHD annually, over 90% do not have access to cardiac care. With the increasing fertility rates in sub-Saharan Africa, the health burden of CHD will increase as well. Over the last 30 years much has been achieved with short term cardiac medical missions. However, much remains to be done to provide long term solutions needed to achieve the sustainable development goal of reducing deaths of children <5 years of age. This review discusses the present status and the need for a paradigm shift to achieve long term sustainability.