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Objective: In this study, we assess the delivery of congenital pediatric surgical care under Brazil's system of universal health coverage and evaluate differences in delivery between public and private sectors. Methods: A cross-sectional national survey of pediatric surgeons in Brazil was conducted. Participants were asked which of 23 interventions identified through the Disease Control Priorities 3 (Surgical Interventions for Congenital Anomalies) they perform and to report barriers faced while providing surgical care. Responses were weighted by state and stratified by sector (public vs private). Results: A sample of 352 responses was obtained and weighted to represent 1378 practicing pediatric surgeons registered in Brazil during the survey time. 73% spend the majority of their time working in the public sector ('Sistema Único de Saúde' and Foundation hospitals), and most of them also work in the private sector. Generally, Brazilian pediatric surgeons have the expertise to provide thoracic, abdominal, and urologic procedures. Surgeons working mostly in the public sector were more likely to report a lack of access to essential medications (25% vs 9%, p<0.01) and a lack of access to hospital beds for surgical patients (52% vs 32%, p<0.01). Conclusions: Brazilian pediatric surgeons routinely perform thoracic, abdominal, and urologic surgery. Those working in government-financed hospitals face barriers related to infrastructure, which may impact Brazilians who rely on Brazil's universal health coverage system. Policies that support pediatric surgeons working in the public sector may promote the workforce available to provide congenital pediatric surgical care.
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Background: Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children's surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices. Methods: A survey of children's surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically. Results: A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children's surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled. Conclusions: There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.
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BACKGROUND: Ethanol lock therapy (ELT) has been reported as being effective in preventing central line-associated bloodstream infection (CLABSI) in tunneled (or long-term) central venous catheters (CVCs). To the best of our knowledge, no studies have evaluated this therapy in relation to nontunneled (or short-term) CVCs. OBJECTIVE: To evaluate the effectiveness of ELT in preventing CLABSI in nontunneled CVC in pediatric patients. METHODS: This randomized clinical trial was conducted with children aged 0-5 years and >2 kg in weight, in whom a double-lumen polyurethane nontunneled CVC had been inserted. Patients with catheters inserted in an emergency situation, critically ill patients, and/or those with a history of hypersensitivity or allergic reactions to ethanol were excluded from the study. The variables evaluated were CLABSI, etiological agents, adverse events, and the mechanical effects of ethanol on the catheter (breakage and obstruction). RESULTS: The CLABSI rate was lower in the ELT group compared with the control group (P = 0.0177). However, when the occurrence of CLABSI was evaluated per 1000 catheter-days, no significant difference was found between the groups (P = 0.077). The frequency of side effects and catheter breakage was greater in the ELT group (P = 0.0001 and P = 0.0005, respectively). CONCLUSIONS: The CLABSI rate was statistically significantly reduced in the ELT group compared with the controls, but the analysis of frequency per catheter-day showed no significant difference between the groups. Thus, we should not recommend ELT for CLABSI prophylaxis in nontunneled polyurethane CVC, which requires further clinical trials.