Correlation of Pediatric Surgical Infrastructure With Clinical and Economic Outcomes: A Cohort Study.

INTRODUCTION: A significant burden of unmet pediatric surgical disease exists in low- and middle-income countries. We sought to assess the associations between the installation of a pediatric operating room (OR) and clinical and economic outcomes for families with children in Ethiopia. METHODS: A retrospective cohort study was performed of children who underwent elective surgery in a tertiary-level Ethiopian public hospital, comparing patient outcomes before and after OR installation in August 2019. Clinical data were collected via chart review, and an inpatient economic survey was administered to patient caregivers. Interrupted time series analysis investigated trends in surgical volume over time. The relative economic benefit was determined by comparing the patients' household income to the monetary health benefit gained using the value of statistical life method. RESULTS: One thousand one hundred and ninety-six patients were included from August 2018 to July 2022. Surgery averted 20,541 disability-adjusted life years (DALYs) cumulatively or 17 DALYs per patient. Monthly case volume and DALYs averted significantly increased postinstallation. The median annual household income of the economic survey responders (n = 339) was $1337 (IQR 669-2592). 27.7% (n = 94/339) lived in extreme poverty, and 41.3% (n = 140/339) experienced catastrophic healthcare expenditure. Net monetary health benefit was $29.3 million or $26,646 per patient. The ratio of net monetary health benefit to household annual income was 60:1. CONCLUSIONS: Installing a pediatric OR in a public Ethiopian hospital ensures increased access to surgery for those most impoverished in Ethiopia and improves equitable access to surgical care. Greater investment in expanding pediatric surgical infrastructure can help address global inequities in child health.

Pediatric Emergency Surgery Course in Uganda: Long-Term Follow-Up and Insights From Further Dissemination.

INTRODUCTION: Approximately 170 pediatric surgeons are needed for the 24 million children in Uganda. There are only seven. Consequently, general surgeons manage many pediatric surgical conditions. In response, stakeholders created the Pediatric Emergency Surgery Course (PESC) for rural providers, given three times in 2018-2019. We sought to understand the course's long-term impact, current pediatric surgery needs, and determine measures for improvement. METHODS: In October 2021, we distributed the same test given in 2018-2019. Student's t-test was used to compare former participants' scores to previous scores. The course was delivered again in May 2022 to new participants. We performed a quantitative needs assessment and also conducted a focus group with these participants. Finally, we interviewed Surgeon in Chiefs at previous sites. RESULTS: Twenty three of the prior 45 course participants re-took the PESC course assessment. Alumni scored on average 71.9% ± 18% correct. This was higher from prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018-2019 postcourse scores 71.9% ± 14%. Fifteen course participants completed the needs assessment. Participants had low confidence managing pediatric surgical disease (median Likert scale ≤ 3.0), 12 of 15 participants endorsed lack of equipment, and eight of 15 desired more educational resources. Qualitative feedback was positive: participants valued the pragmatic lessons and networking with in-country specialists. Further training was suggested, and Chiefs noted the need for more trained staff like anesthesiologists. CONCLUSIONS: Participants favorably reviewed PESC and retained knowledge over three years later. Given participants' interest in more training, further investment in locally derived educational efforts must be prioritized.

Children's surgery and the emergency, critical, and operative care resolution: Immediate actions to eliminate disparities in surgery, anesthesia, and perioperative care for all children.

Around 1.7 billion children lack access to surgical care worldwide. To reinvigorate the efforts to address these disparities and support work to address global challenges in surgery, anesthesia, emergency, and critical care, the World Health Assembly passed World Health Organization Resolution World Health Assembly 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (ECO) in 2023. This resolution highlights the integral role of surgery, anesthesia, and perioperative care in health systems. However, understanding how best to operationalize this resolution is challenging. We review the ECO resolution and highlight points that the pediatric surgical and anesthesia community can leverage to advocate for its recommendations for operative care.

Children's surgery and the emergency, critical, and operative care resolution: immediate actions to eliminate disparities in surgical anesthesia and perioperative care for all children.

1.7 billion children lack access to surgical care worldwide. The emergency, critical, and operative care (ECO) resolution represents a call to action to reinvigorate the efforts to address these disparities. We review the ECO resolution and highlight the avenues that may be utilized in advocating for children's surgical care.

Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Treatment abandonment in children with Wilms tumor at a national referral hospital in Uganda.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Leveraging Existing Datasets to Advance Family Caregiving Research: Opportunities to Measure What Matters.

More than 17.7 million people in the U.S. care for older adults. Analyzing population datasets can increase our understanding of the needs of family caregivers of older adults. We reviewed 14 U.S. population-based datasets (2003-2023) including older adults' and caregivers' data to assess inclusion and measurement of 8 caregiving science domains, with a focus on whether measures were validated and/or unique variables were used. Challenges exist related to survey design, sampling, and measurement. Findings highlight the need for consistent data collection by researchers, state, tribal, local, and federal programs, for improved utility of population-based datasets for caregiving and aging research.

Pediatric Trauma Care Standardization: A Statewide Survey of Trauma Providers and Program Managers.

INTRODUCTION: Rural-urban disparities in pediatric trauma outcomes are well documented. However, few studies examine how differences in setting and resources impact rural providers' approach to trauma. We sought to understand the provider experience in managing injured children across our state and assess the potential for standardization of care. METHODS: A statewide cross-sectional survey was distributed to trauma providers and program managers through the American College of Surgeons, the Oregon Medical Board lists, and the State Trauma Advisory Board. Topics included pediatric management processes, challenges, and transfer or admission procedures. Rural-urban commuting codes were used to categorize responses. RESULTS: Of the 350 individuals who sent the survey, 68 responded (response rate 19%), representing 67% of trauma-verified hospitals and 72% of Oregon counties. Fifty-six respondents (82%) care for injured children, with 58% practicing rurally and 22% at critical access hospitals. Rural providers experienced lower trauma volumes (<1 patient/month, 63% versus 0%, P < 0.001), more difficulties obtaining pediatric-appropriate material resources (44% versus 30%), and challenges caring for infants/toddlers (25% versus 17%). Despite 77% of rural providers stating that <10% of patients had multisystem injuries, they described using full-body CT often (41% versus 10%, P = 0.007). Transfer interruptions were common (93%), with 44% having cancelled a transfer. The majority supported admission/transfer (85%) and imaging (82%) protocols. CONCLUSIONS: Rural providers experience lower pediatric trauma volumes, greater material-resource issues, and discomfort with traumatically injured small children. Lack of care standardization may lead to reliance on full-body CT, and potentially complex/avoidable transfers. Adoption of standardized protocols could facilitate a state-wide collaborative approach to pediatric trauma management.

Factors associated with mobile medical clinic use: a retrospective cohort study.

BACKGROUND: Mobile medical clinics have been used for decades to provide primary and preventive care to underserved populations. While several studies have examined their return on investment and impact on chronic disease management outcomes in the Mid-Atlantic and East Coast regions of the United States, little is known about the characteristics and clinical outcomes of adults who receive care aboard mobile clinics on the West Coast region. Guided by the Anderson Behavioral Model, this study describes the predisposing, enabling, and need factors associated with mobile medical clinic use among mobile medical clinic patients in Southern California and examines the relationship between mobile clinic utilization and presence and control of diabetes and hypertension. METHODS: We conducted a retrospective cohort study of 411 adults who received care in four mobile clinic locations in Southern California from January 1, 2018, to December 31, 2019. Data were collected from patient charts on predisposing (e.g., sex, race, age), enabling (e.g., insurance and housing status), and need (e.g., chronic illness) factors based on Andersen's Behavioral Model. Zero-truncated negative binomial regression was used to examine the association of chronic illness (hypertension and diabetes) with number of clinic visits, accounting for potential confounding factors. RESULTS: Over the course of the 2-year study period, 411 patients made 1790 visits to the mobile medical clinic. The majority of patients were female (68%), Hispanic (78%), married (47%), with a mean age of 50 (SD = 11). Forty-four percent had hypertension and 29% had diabetes. Frequency of mobile clinic utilization was significantly associated with chronic illness. Patients with hypertension and diabetes had 1.22 and 1.61 times the rate of mobile medical clinic visit than those without those conditions, respectively (IRR = 1.61, 95% CI, 1.36-1.92; 1.22, 95% CI, 1.02-1.45). CONCLUSIONS: Mobile clinics serve as an important system of health care delivery, especially for adults with uncontrolled diabetes and hypertension.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Disparities and determinants of place of death: Insights from the Utah Population Database.

To better understand determinants and potential disparities in end of life, we model decedents' place of death with explanatory variables describing familial, social, and economic resources. A retrospective cohort of 204,041 decedents and their family members are drawn from the Utah Population Database family caregiving dataset. Using multinomial regression, we model place of death, categorized as at home, in a hospital, in another location, or unknown. The model includes family relationship variables, sex, race and ethnicity, and a socioeconomic status score, with control variables for age at death and death year. We identified the effect of a family network of multiple caregivers, with 3+ daughters decreasing odds of a hospital death by 17 percent (OR: 0.83 [0.79, 0.87], p < 0.001). Place of death also varies significantly by race and ethnicity, with most nonwhite groups more likely to die in a hospital. These determinants may contribute to disparities in end of life.

Failure of primary closure predicts prolonged length of stay in gastroschisis patients.

PURPOSE: Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding. METHODS: We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes. RESULTS: Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure. CONCLUSION: Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Advances in geropsychiatric nursing: A decade in review.

This article provides a brief overview of the early development of geropsychiatric nursing (GPN) as background for examining its advancement subsequent to the 2010 Future of Nursing (FON) Report. The FON's education, practice and leadership recommendations form the three pillars that have supported geropsychiatric nursing's continuing evolution, framed within a practice and policy perspective. Lessons learned are relevant to developing the next phase of FON recommendations. The importance of overcoming challenges faced by the field of GPN is supported by the aging global population, the directions of nursing as a discipline, and the clear necessity of an intra- and inter-professional approach to mental health and aging.

Postimplementation Evaluation of a Machine Learning-Based Deterioration Risk Alert to Enhance Sepsis Outcome Improvements.

Machine learning-based early warning systems (EWSs) can detect clinical deterioration more accurately than point-score tools. In patients with sepsis, however, the timing and scope of sepsis interventions relative to an advanced EWS alert are not well understood. The objectives of this study were to evaluate the timing and frequency of fluid bolus therapy, new antibiotics, and Do Not Resuscitate (DNR) status relative to the time of an advanced EWS alert. We conducted 2 rounds of chart reviews of patients with an EWS alert admitted to community hospitals of a large integrated health system in Northern California (round 1: n = 21; round 2: n = 47). We abstracted patient characteristics and process measures of sepsis intervention and performed summary statistics. Sepsis decedents were older and sicker at admission and alert time. Most EWS alerts occurred near admission, and most sepsis interventions occurred before the first alert. Of 14 decedents, 12 (86%) had a DNR order before death. Fluid bolus therapy and new intravenous antibiotics frequently occurred before the alert, suggesting a potential overlap between sepsis care in the emergency department and the first alert following admission. Two tactics to minimize alerts that may not motivate new sepsis interventions are (1) locking out the alert during the immediate time after hospital admission; and (2) triaging and reviewing patients with alerts outside of the unit before activating a bedside response. Some decedents may have been on a palliative/end-of-life trajectory, because DNR orders were very common among decedents. Nurse leaders sponsoring or leading machine learning projects should consider tactics to reduce false-positive and clinically meaningless alerts dispatched to clinical staff.

Interactions of Pseudomonas aeruginosa with Acanthamoeba polyphaga Observed by Imaging Flow Cytometry.

Pseudomonas aeruginosa is a Gram-negative bacterium that is abundant in the environment and water systems, with strains that cause serious infections, especially in patients with compromised immune systems. In times of stress or as part of its natural life cycle, P. aeruginosa can adopt a viable but not culturable (VBNC) state, which renders it undetectable by current conventional food and water testing methods and makes it highly resistant to antibiotic treatment. Specific conditions can resuscitate these coccoid VBNC P. aeruginosa cells, which returns them to their active, virulent rod-shaped form. Underreporting the VBNC cells of P. aeruginosa by standard culture-based methods in water distribution systems may therefore pose serious risks to public health. As such, being able to accurately detect and quantify the presence of VBNC P. aeruginosa, especially in a hospital setting, is of critical importance. Herein, we describe a method to analyze VBNC P. aeruginosa using imaging flow cytometry. With this technique, we can accurately distinguish between active and VBNC forms. We also show here that association of VBNC P. aeruginosa with Acanthamoeba polyphaga results in resuscitation of P. aeruginosa to an active form within 2 h. Our approach could provide an alternative, reliable detection method of VBNC P. aeruginosa when coupled with species-specific staining. Most importantly, our experiments demonstrate that the coculture with amoebae can lead to a resuscitation of P. aeruginosa of culturable morphology after only 2 h, indicating that VBNC P. aeruginosa could potentially resuscitate in piped water (healthcare) environments colonized with amoebae. © 2019 International Society for Advancement of Cytometry.

Ethics in Global Pediatric Surgery: Existing Dilemmas and Emerging Challenges.

The rapid growth of global pediatric surgery beyond direct care delivery into research, education, and advocacy necessitates re-evaluation of the traditional ethical paradigms which have governed our partnerships in low- and middle-income countries (LMIC). Within this paper, we consider current and emerging ethical challenges and discuss principles to consider in order to promote autonomous systems for pediatric surgical care in LMIC.

Utilizing Technology for Global Surgery: A Survey of the West African College of Surgeons.

BACKGROUND: Information and communication technology (ICT) has been heralded as a possible mechanism for expanding global surgery collaborations. However, little is known regarding feasibility of ICT use in low- and middle-income countries (LMIC). We sought to determine the appropriate ICT platforms for surgical education initiatives and international collaborations. MATERIALS AND METHODS: We conducted a survey of members of the West African College of Surgeons. Topics included computer and internet access/utilization, familiarity with ICT, such as social media (SM), virtual document sharing platforms (VDS), virtual meeting applications (VM), and learning management systems (LM), and interest in ICT adoption. Statistical analyses were done using chi-squared tests, with Bonferroni corrections. RESULTS: Survey respondents included 83 individuals from 10 countries, 50% of whom had been in practice >10 y. All had computer access, with most (95%) using SM compared to all other modalities (P < 0.001); 77% used SM for professional reasons and 57% for education. Sixty percent of participants used VDS, 73% of whom used it for education. The utilization of other ICTs was lower (VM 43%, LM 32%). Unreliable Wi-Fi hindered every ICT, less often SM (41%) and VDS (23%), and more commonly VM (64%) and LM (52%). Despite this, VM was most often used in international collaboration (79%, P < 0.01). Most respondents (98%) supported ICT use for international collaboration. CONCLUSIONS: ICT platforms can support education initiatives and international collaborations in resource-limited areas. Deployment of similar surveys and ICT workshops across other LMIC regions could maximize ICT utilization, further expanding global surgical collaborations.

Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review.

As part of the National Plan to Address Alzheimer's Disease, reducing potentially avoidable emergency department (ED) use by individuals with dementia has been identified as a component of enhancing the quality and efficiency of care for this population. To help inform the development of interventions to achieve this goal, an integrative review was conducted to: (a) compare rates and reasons for ED visits by community-dwelling individuals with and without dementia, considering also the effect of dementia subtype and severity; and (b) identify other risk factors for increased ED use among community-dwelling individuals with dementia. Nineteen articles met inclusion criteria. Individuals with dementia had higher rates of ED visits compared to those without dementia, although differences were attenuated in the last year of life. Increased symptoms and disability were associated with increased rates of ED visits, whereas resources that enabled effective management of increased need decreased rates. Gerontological nurses across settings are on the frontlines of preventing potentially avoidable ED visits by community-dwelling individuals with dementia through patient and family education and leadership in the development of new models of care. [Journal of Gerontological Nursing, 44(3), 23-30.].

Expansion of the role of web-based social networks related to synthetic mesh/tape complications.

PURPOSE: To update a prior report on web-based networks and frequently visited forums used by patients affected by synthetic mesh and/or tape (SMT) complications and to present the new developments in this dynamic SMT field following recent FDA notifications. METHODS: A review of available blogs and forums on SMT complications was conducted using the terms "mesh complications", "mesh blogs", and "polypropylene mesh removal" in Internet search engines for the United States and several other countries. Forums from a prior report were analyzed for updates, and new forums with their founders were identified using same search methodology. The number of posts and new fields from 07/2011 to 10/2013 was recorded, and then divided into categories based on broad content (personal stories, supportive replies to complaints, patients recommending physicians, legal stories, newspaper/article stories with reactions, other). RESULTS: Although four social networks became inactive, four expanded and at least five new major ones surfaced. While personal stories and support remained a prominent topic of discussion, other categories increased, such as the number of posts discussing physician referrals and reactions to news stories. Additionally, the number of posts designated to personal stories decreased. Finally, discussion about the topic expanded internationally. CONCLUSION: Web-based social networks for women suffering from SMT have expanded and the contents have broadened with new domains being introduced. Patient networking remains a dynamic force in the current debate on the future of these procedures.