Disparities in surgical care for children across Brazil: Use of geospatial analysis.

BACKGROUND: Health systems for surgical care for children in low- and middle-income countries remain poorly understood. Our goal was to characterize the delivery of surgical care for children across Brazil and to identify associations between surgical resources and childhood mortality. METHODS: We performed a cross-sectional, ecological study to analyze surgical care for children in the public health system (Sistema Único de Saúde) across Brazil from 2010 to 2015. We collected data from several national databases, and used geospatial analysis (two-step floating catchment, Getis-Ord-Gi analysis, and geographically weighted regression) to explore relationships between infrastructure, workforce, access, procedure rate, under-5 mortality rate (U5MR), and perioperative mortality rate (POMR). RESULTS: A total of 246,769 surgical procedures were performed in 6,007 first level/ district hospitals and 491 referral hospitals across Brazil over the study period. The surgical workforce is distributed unevenly across the country, with 0.13-0.26 pediatric surgeons per 100,000 children in the poorer North, Northeast and Midwest regions, and 0.6-0.68 pediatric surgeons per 100,000 children in the wealthier South and Southeast regions. Hospital infrastructure, procedure rate, and access to care is also unequally distributed across the country, with increased resources in the South and Southeast compared to the Northeast, North, and Midwest. The U5MR varies widely across the country, although procedure-specific POMR is consistent across regions. Increased access to care is associated with lower U5MR across Brazil, and access to surgical care differs by geographic region independent of socioeconomic status. CONCLUSIONS: There are wide disparities in surgical care for children across Brazil, with infrastructure, manpower, and resources distributed unevenly across the country. Access to surgical care is associated with improved U5MR independent of socioeconomic status. To address these disparities, policy should direct the allocation of surgical resources commensurate with local population needs.

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

BACKGROUND: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.

Does This Patient Have a Severe Snake Envenomation?: The Rational Clinical Examination Systematic Review.

Importance: Venomous snakebite severity ranges from an asymptomatic dry bite to severe envenomation and death. The clinical evaluation aids in prognosis and is essential to determine the risks and potential benefits of antivenom treatment. Objectives: To identify historical features, clinical examination findings, basic laboratory testing, and clinical grading scales that will risk-stratify patients with pit viper snake envenomation for severe systemic envenomation, severe tissue injury, and/or severe hematologic venom effects. Data Sources: We conducted a structured search of PubMed (1966-October 3, 2017) and Embase database (1980-October 3, 2017) to identify English-language studies that evaluated clinical features predictive of severe envenomation. Study Selection: We included studies that evaluated the test performance of at least 1 clinical finding with an acceptable reference standard of severe envenomation for venomous snakes of the Western Hemisphere. Only studies involving the most common subfamily, Crotalinae (pit vipers), were evaluated. Seventeen studies with data were available for abstraction. Data Extraction and Synthesis: The clinical features assessed and severity outcome measures were extracted from each original study. We assessed severity in 3 categories: systemic toxicity, tissue injury, and hematologic effects. Differences were resolved by author consensus. Results: The pooled prevalence of severe systemic envenomation was 14% (95% CI, 9%-21%). The pooled prevalence of severe tissue injury and severe hematologic venom effects were 14% (95% CI, 12%-16%) and 18% (95% CI, 8%-27%), respectively. Factors increasing the likelihood of severe systemic envenomation included the time from bite to care of 6 or more hours (likelihood ratio [LR], 3.4 [95% CI, 1.1-6.4]), a patient younger than 12 years (LRs, 3.2 [95% CI, 1.5-7.1] and 2.9 [95% CI, 1.3-6.2]), large snake size (LR, 3.1 [95% CI, 1.5-5.7]), and ptosis (LRs, 1.4 [95% CI, 1.0-2.1] and 3.8 [95% CI, 1.8-8.3]). Envenomation by the genus Agkistrodon (copperhead and cottonmouth), as opposed to rattlesnakes, decreased the likelihood of severe systemic envenomation (LR, 0.28 [95% CI, 0.10-0.78]). Initial hypofibrinogenemia (LR, 5.1 [95% CI, 1.7-15.0]) and thrombocytopenia (LR, 3.7 [95% CI, 1.9-7.3]) increased the likelihood of severe hematologic venom effects. Other clinical features from history, physical examination, or normal laboratory values were not discriminative. Conclusions: Clinical features can identify patients at increased risk of severe systemic envenomation and severe hematologic venom effects, but there are few features that are associated with severe tissue injury or can confidently exclude severe envenomation. Physicians should monitor patients closely and be wary of progression from nonsevere to a severe envenomation and have a low threshold to escalate therapy as needed.