Integrating traffic safety data with area deprivation index: A method to better understand the causes of pediatric pedestrian versus automobile collisions.

BACKGROUND: The purpose of this study was to identify clinical and traffic factors that influence pediatric pedestrian versus automobile collisions (P-ACs) with an emphasis on health care disparities. METHODS: A retrospective review was performed of pediatric (18 years or younger) P-ACs treated at a Level I pediatric trauma center from 2008 to 2018. Demographic, clinical, and traffic scene data were analyzed. Area deprivation index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) based on home addresses. Traffic scene data from the California Statewide Integrated Traffic Records System were matched to clinical records. Traffic safety was assessed by the streetlight coverage, the proximity of the collision to home addresses, and sidewalk coverage. Descriptive statistics and univariate analysis for key variables and outcomes were calculated using Kruskal-Wallis, Wilcoxon, χ 2 , or Fisher's exact tests. Statistical significance was attributed to p values of <0.05. RESULTS: Among 770 patients, the majority were male (65%) and Hispanic (54%), with a median age of 8 years (interquartile range, 4-12 years). Hispanic patients were more likely to live in more disadvantaged neighborhoods than non-Hispanic patients (67% vs. 45%, p < 0.01). There were no differences in clinical characteristics or outcomes across ADI quintiles. Using the Statewide Integrated Traffic Records System (n = 272), patients with more NSD were more likely injured during dark streetlight conditions (15% vs. 4% least disadvantaged; p = 0.04) and within 0.5 miles from home ( p < 0.01). Pedestrian violations were common (65%). During after-school hours, 25% were pedestrian violations, compared with 12% driver violations ( p = 0.02). CONCLUSION: A larger proportion of Hispanic children injured in P-ACs lived in neighborhoods with more socioeconomic disadvantage. Hispanic ethnicity and NSD are each independently associated with P-ACs. Poor streetlight conditions and close proximity to home were associated with the most socioeconomically disadvantaged neighborhoods. This research may support targeted prevention programs to improve pedestrian safety in children. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Assessment of Surgical Care Provided in National Health Services Hospitals in Mozambique: The Importance of Subnational Metrics in Global Surgery.

INTRODUCTION: Surgery plays a critical role in sustainable healthcare systems. Validated metrics exist to guide implementation of surgical services, but low-income countries (LIC) struggle to report recommended metrics and this poses a critical barrier to addressing unmet need. We present a comprehensive national sample of surgical encounters from a LIC by assessing the National Health Services of Mozambique. MATERIAL AND METHODS: A prospective cohort of all surgical encounters from Mozambique's National Health Service was gathered for all provinces between July and December 2015. Primary outcomes were timely access, provider densities for surgery, anesthesiology, and obstetrics (SAO) per 100,000 population, annualized surgical procedure volume per 100,000, and postoperative mortality (POMR). Secondary outcomes include operating room density and efficiency. RESULTS: Fifty-four hospitals had surgical capacity in 11 provinces with 47,189 surgeries. 44.9% of Mozambique's population lives in Districts without access to surgical services. National SAO density was 1.2/100,000, ranging from 0.4/100,000 in Manica Province to 9.8/100,000 in Maputo City. Annualized national surgical case volume was 367 procedures/100,000 population, ranging from 180/100,000 in Zambezia Province to 1,897/100,000 in Maputo City. National POMR was 0.74% and ranged from 0.23% in Maputo Province to 1.78% in Niassa Province. DISCUSSION: Surgical delivery in Mozambique falls short of international targets. Subnational deficiencies and variations between provinces pose targets for quality improvement in advancing national surgical plans. This serves as a template for LICs to follow in gathering surgical metrics for the WHO and the World Bank and offers short- and long-term targets for surgery as a component of health systems strengthening.

Assessment of a Nutritional Rehabilitation Model in Two Modern Broilers and Their Jungle Fowl Ancestor: A Model for Better Understanding Childhood Undernutrition.

This article is the first in a series of manuscripts to evaluate nutritional rehabilitation in chickens as a model to study interventions in children malnutrition (Part 1: Performance, Bone Mineralization, and Intestinal Morphometric Analysis). Inclusion of rye in poultry diets induces a nutritional deficit that leads to increased bacterial translocation, intestinal viscosity, and decreased bone mineralization. However, it is unclear the effect of diet on developmental stage or genetic strain. Therefore, the objective was to determine the effects of a rye diet during either the early or late phase of development on performance, bone mineralization, and intestinal morphology across three diverse genetic backgrounds. Modern 2015 (Cobb 500) broiler chicken, 1995 Cobb broiler chicken, and the Giant Jungle Fowl were randomly allocated into four different dietary treatments. Dietary treatments were (1) a control corn-based diet throughout the trial (corn-corn); (2) an early phase malnutrition diet where chicks received a rye-based diet for 10 days, and then switched to the control diet (rye-corn); (3) a malnutrition rye-diet that was fed throughout the trial (rye-rye); and (4) a late phase malnutrition diet where chicks received the control diet for 10 days, and then switched to the rye diet for the last phase (corn-rye). At 10 days of age, chicks were weighed and diets were switched in groups 2 and 4. At day 20 of age, all chickens were weighed and euthanized to collect bone and intestinal samples. Body weight, weight gain, and bone mineralization were different across diet, genetic line, age and all two- and three-way interactions (P < 0.05). Overall, Jungle Fowl were the most tolerant to a rye-based diet, and both the modern and 1995 broilers were significantly affected by the high rye-based diet. However, the 1995 broilers consuming the rye-based diet appeared to experience more permanent effects when compared with the modern broiler. The results of this study suggest that chickens have a great potential as a nutritional rehabilitation model in human trials. The 1995 broilers line was an intermediate genetic line between the fast growing modern line and the non-selected Jungle Fowl line, suggesting that it would be the most appropriate model to study for future studies.

Out of Africa: Insights from a prospective pediatric surgery database.

In this year's Robert E. Gross lecture, I describe how experiences early in my career at a government referral hospital in Banjul, The Gambia, influenced my research. Collecting prospective data on all children presenting to the hospital with surgical problems allowed me to gain an understanding of the epidemiology of childhood surgical conditions in sub-Saharan Africa and an appreciation for the inherent challenges of delivering surgical care in settings of limited resources. Based on findings from this database, my research over the past 20years has focused on developing strategies for improving surgical care in low-income countries and better understanding the geographical variations that occur in some of the most common surgical conditions in high-income countries (e.g., appendicitis). Although this research continues to be a work-in-progress, it has the potential to improve the surgical care of children in both high- and low-income countries. Much of this research would not have been possible had I not ventured off the usual path for an academic surgeon.

An investment in knowledge: Research in global pediatric surgery for the 21st century.

The body of literature addressing surgical and anesthesia care for children in low- and middle-income countries (LMICs) is small. This lack of research hinders full understanding of the nature of many surgical conditions in LMICs and compromises potential efforts to alleviate the significant health, welfare and economic burdens surgical conditions impose on children, families and countries. This article will evaluate the need for improved global pediatric surgery research by (1) presenting the current state of surgical research for children in LMICs and (2) discussing methods and opportunities for improvement within the political context of current global health priorities.

Improving surgical systems in low- and middle-income countries: an inclusive framework for monitoring and evaluation.

High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.

Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates.

BACKGROUND: We previously identified a range of 4344-5028 annual operations per 100,000 people to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100,000 people. We evaluate rates of growth and estimate the time it will take to reach this minimum surgical rate threshold. METHODS: We aggregated country-level surgical rate estimates from 2004 to 2012 into the twenty-one Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size for each year and assessed the rate of growth over time. We then extrapolated the time it will take each region to reach a surgical rate of 5000 operations per 100,000 population based on linear rates of change. RESULTS: All but two regions experienced growth in their surgical rates during the past 8 years. Fourteen regions did not meet the recommended threshold in 2012. If surgical capacity continues to grow at current rates, seven regions will not meet the threshold by 2035. Eastern Sub-Saharan Africa will not reach the recommended threshold until 2124. CONCLUSION: The rates of growth in surgical service delivery are exceedingly variable. At current rates of surgical and population growth, 6.2 billion people (73% of the world's population) will be living in countries below the minimum recommended rate of surgical care in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met in a timely fashion as part of the integrated health system development.

The role of facility-based surgical services in addressing the national burden of disease in New Zealand: An index of surgical incidence based on country-specific disease prevalence.

BACKGROUND: Surgery is a crucial component of health systems, yet its contribution has been difficult to define. We linked national hospital service utilization with national epidemiologic data to describe the use of surgical procedures in the management of a broad spectrum of conditions. METHODS: We compiled International Classification of Diseases-10-Australian Modification codes from the New Zealand National Minimum Dataset, 2008-2011. Using primary cause of admission, we aggregated hospitalizations into 119 disease states and 22 disease subcategories of the World Health Organization Global Health Estimate (GHE). We queried each hospitalization for any surgical procedure in a binary manner to determine the volume of surgery for each disease state. Surgical procedures were defined as requiring general or neuroaxial anesthesia. We then divided the volume of surgical cases by counts of disease prevalence from the Global Burden of Disease Study 2010 to determine annual surgical incidence. RESULTS: Between 2008 and 2011, there were 1,108,653 hospital admissions with 275,570 associated surgical procedures per year. Surgical procedures were associated with admissions for all 22 GHE disease subcategories and 116 of 119 GHE disease states. The sub-categories with the largest surgical case volumes were Unintentional Injuries (48,073), Musculoskeletal Diseases (38,030), and Digestive Diseases (27,640). Surgical incidence ranged widely by individual disease states with the highest in: Other Neurological Conditions, Abortion, Appendicitis, Obstructed Labor, and Maternal Sepsis. CONCLUSION: This study confirms that surgical care is required across the entire spectrum of GHE disease subcategories, illustrating a critical role in health systems. Surgical incidence might be useful as an index to estimate the need for surgical procedures in other populations.

Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate.

BACKGROUND: Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD). METHODS: Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO's Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region. FINDINGS: We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries. INTERPRETATION: The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems. FUNDING: US National Institutes of Health.

Timing and cost of scaling up surgical services in low-income and middle-income countries from 2012 to 2030: a modelling study.

BACKGROUND: Given the large burden of surgical conditions and the crosscutting nature of surgery, scale-up of basic surgical services is crucial to health-system strengthening. The Lancet Commission on Global Surgery proposed that, to meet populations' needs, countries should achieve 5000 major operations per 100 000 population per year. We modelled the possible scale-up of surgical services in 88 low-income and middle-income countries with a population greater than 1 million from 2012 to 2030 at various rates and quantified the associated costs. METHODS: Major surgery includes any intervention within an operating room involving tissue manipulation and anaesthesia. We used estimates for the number of major operations achieved per country annually and the number of operating rooms per region, and data from Mongolia and Mexico for trends in the number of operations. Unit costs included a cost per operation, proxied by caesarean section cost estimates; hospital construction data were used to estimate cost per operating room construction. We determined the year by which each country would achieve the Commission's target. We modelled three scenarios for the scale-up rate: actual rates (5·1% per year) and two "aspirational" rates, the rates achieved by Mongolia (8·9% annual) and Mexico (22·5% annual). We subsequently estimated the associated costs. FINDINGS: About half of the 88 countries would achieve the target by 2030 at actual rates of improvements, with up to two-thirds if the rate were increased to Mongolian rates. We estimate the total costs of achieving scale-up at US$300-420 billion (95% UI 190-600 billion) over 2012-30, which represents 4-8% of total annual health expenditures among low-income and lower middle-income countries and 1% among upper middle-income countries. INTERPRETATION: Scale-up of surgical services will not reach the target of 5000 operations per 100 000 by 2030 in about half of low-income and middle-income countries without increased funding, which countries and the international community must seek to achieve expansion of quality surgical services. FUNDING: None.

Surgical Care and Health Systems.

BACKGROUND: While surgical care impacts a wide variety of diseases and conditions with non-operative and operative services, both preventive and curative, there has been little discussion concerning how surgery might be integrated within the health system of a low and middle-income country (LMIC), nor how strengthening surgical services may improve health systems and population health. METHODS: We reviewed reports from several meetings of the working group on health systems strengthening of the Global Initiative for Emergency and Essential Surgical Care, and also performed a review of the literature including the search terms "surgery," "health system," "developing country," "health systems strengthening," "health information system," "financing," "governance," and "integration." RESULTS: The literature search revealed no reports which focused on the integration of surgical services within a health system or as a component of health system strengthening. A conceptual model of how surgical care might be integrated within a health system is proposed, based on the discussions of our working group, combined with sources from the medical literature, and utilizing the World Health Organization's conceptual model of a health system. CONCLUSIONS: Strengthening the delivery of surgical services in LMICs will require inputs at multiple levels within a health system, and this effort will require the coalescence of committed individuals and organizations, supported by civil society.

The burden of selected congenital anomalies amenable to surgery in low and middle-income regions: cleft lip and palate, congenital heart anomalies and neural tube defects.

OBJECTIVE: To quantify the burden of selected congenital anomalies in low and middle-income countries (LMICs) that could be reduced should surgical programmes cover the entire population with access to quality care. DESIGN: Burden of disease and epidemiological modelling. SETTING: LMICs from all global regions. POPULATION: All prevalent cases of selected congenital anomalies at birth in 2010. MAIN OUTCOME MEASURES: Disability-adjusted life years (DALYs). INTERVENTIONS AND METHODS: Surgical programmes for three congenital conditions were analysed: clefts (lip and palate); congenital heart anomalies; and neural tube defects. Data from the Global Burden of Disease 2010 Study were used to estimate the combination of fatal burden that could be addressed by surgical care and the additional long-term non-fatal burden associated with increased survival. RESULTS: Of the estimated 21.6 million DALYs caused by these three conditions in LMICs, 12.4 million DALYs (57%) are potentially addressable by surgical care among the population born with such conditions. Neural tube defects have the largest potential with 76% of burden amenable by surgery, followed by clefts (59%) and congenital heart anomalies (49%). Sub-Saharan Africa and South Asia have the greatest proportion of surgically addressable burden for clefts (68%), North Africa and Middle East for congenital heart anomalies (73%), and South Asia for neural tube defects (81%). CONCLUSIONS: There is an important and neglected role surgical programmes can play in reducing the burden of congenital anomalies in LMICs.

Surgical patients travel longer distances than non-surgical patients to receive care at a rural hospital in Mozambique.

BACKGROUND: Surgical care is increasingly recognised as an important component of global health delivery. However, there are still major gaps in knowledge related to access to surgical care in low-income countries. In this study, we compare distances travelled by surgical patients with patients seeking other medical services at a first-level hospital in rural Mozambique. METHODS: Data were collected on all inpatients at Hospital Rural de Chókwè in rural Mozambique between 20 June 2012 and 3 August 2012. Euclidean distances travelled by surgical versus non-surgical patients using coordinates of each patient's city of residence were compared. Data were analysed using ArcGIS 10 and STATA. RESULTS: In total, 500 patients were included. Almost one-half (47.6%) lived in the city where the hospital is based. By hospital ward, the majority (62.0%) of maternity patients came from within the hospital's city compared with only 35.2% of surgical patients. The average distance travelled was longest for surgical patients (42 km) compared with an average of 17 km for patients on all other wards. CONCLUSIONS: Patients seeking surgical care at this first-level hospital travel farther than patients seeking other services. While other patients may have access to at community clinics, surgical patients depend more heavily on the services available at first-level hospitals.