Gender-Based Discrimination Among Medical Students: A Cross-Sectional Study in Brazil.

INTRODUCTION: Gender-based discrimination (GBD) creates a hostile environment during medical school, affecting students' personal life and academic performance. Little is known about how GBD affects the over 204,000 medical students in Brazil. This study aims to explore the patterns of GBD experienced by medical students in Brazil. METHODS: This is a cross-sectional study using an anonymous, Portuguese survey disseminated in June 2021 among Brazilian medical students. The survey was composed of 24 questions to collect data on GBD during medical school, formal methods for reporting GBD, and possible solutions for GBD. RESULTS: Of 953 responses, 748 (78%) were cisgender women, 194 (20%) were cisgender men, and 11 (1%) were from gender minorities. 65% (616/942) of respondents reported experiencing GBD during medical school. Women students experienced GBD more than men (77% versus 22%; P < 0.001). On comparing GBD perpetrator roles, both women (82%, 470/574) and men (64%, 27/42) reported the highest rate of GBD by faculty members. The occurrence of GBD by location differed between women and men. Only 12% (115/953) of respondents reported knowing their institution had a reporting mechanism for GBD. CONCLUSIONS: Most respondents experienced GBD during medical school. Cisgender women experienced GBD more than cisgender men. Perpetrators and location of GBD differed for men and women. Finally, an alarming majority of students did not know how to formally report GBD in their schools. It is imperative to adopt broad policy changes to diminish the rate of GBD and its a consequential burden on medical students.

Analysis of authorship trends in vascular surgery demonstrates a sticky surgical floor for women.

OBJECTIVE: Prior research in vascular surgery has identified significant gender disparities in leadership positions, but few data exist regarding gender disparities in vascular publications. This study aims to evaluate authorship trends by gender in the three highest impact factor vascular surgery journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in the European Journal of Vascular and Endovascular Surgery, the Journal of Vascular Surgery, and Annals of Vascular Surgery from 2015 to 2019. The web-based application Genderize used predictive algorithms to classify names of first and last authors as male or female. Statistical analyses regarding trends in authorship were performed using Stata16. RESULTS: A total of 6457 articles were analyzed, with first author gender predicted with >90% confidence in 83% (4889/5796) and last author gender in 88% (5078/5796). Overall, 25% (1223/4889) of articles had women first authors, and 10% (501/5078) had women last authors. From 2015 to 2019, there was a slight increase in the proportion of articles written by women first authors (P = .001), but no increase in the proportion of articles written by women last authors (P = .204). The proportion of articles written by women last authors was lower than the proportion of active women vascular surgeons in 2015 (8% of articles vs 11% of surgeons; P = .015), 2017 (9% of articles vs 13% of surgeons; P < .001), and 2019 (11% of articles vs 15% of practicing surgeons; P < .001). The average number of last-author publications was higher for men (2.35 ± 3.76) than for women (1.62 ± 1.88, P = .001). The proportion of unique authors who were women was less than the proportion of active women vascular surgeons in 2017 (10% unique authors vs 13% surgeons; P = .047), but not in 2015 (9% unique authors vs 11% surgeons; P = .192) or 2019 (13% unique authors vs 15% surgeons; P = .345). Notably, a woman last author was associated with 1.45 higher odds of having a woman first author (95% confidence interval, 1.17-1.79; P = .001). CONCLUSIONS: Over the past 5 years, there has been no significant increase in women last authors among top-tier journals in vascular surgery. Women remain under-represented as last authors in terms of proportion of published articles, but not in terms of proportion of unique authors. Nevertheless, women last authors are more likely to publish with women first authors, indicating the importance of women-led mentorship in achieving publication gender equity. Support for women surgeons through grants and promotions is essential not only for advancing last authorship gender equity, but for advancing junior faculty and trainee academic careers.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers.

INTRODUCTION: Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil. METHODS: Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated. RESULTS: Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020. CONCLUSIONS: In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.

Assessing Brazilian Medical Student Awareness About Global Surgery: A Survey-Based Study.

BACKGROUND: Global surgery is an interdisciplinary field that advocates for access to equitable, affordable surgical services for all people. Engaging medical students in the field can strengthen the surgical workforce in low- and middle-income countries. We aim to investigate Brazilian medical students' acknowledgment of global surgery and their preferred learning platforms. MATERIALS AND METHODS: We performed a cross-sectional study through an anonymous Portuguese survey on Google Forms, consisting of 30 mixed multiple-choice and five-point Likert scale questions. Students enrolled in a Brazilian medical school from the second to sixth academic year fulfilled inclusion criteria. The association between qualitative variables was assessed using Chi-square, Fisher's exact test, or binary logistic model. RESULTS: We received 1,345 responses from 208 medical schools. Only 20.9% (282/1,345) of participants reported awareness of global surgery, who were predominantly female. 96.5% (1,298/1,345) declared interest in knowing more about global surgery and participants indicated social media (71.6%, 202/282) as the prevalent manner to gain awareness on it, followed by webinars (63.5%, 179/282). Extracurricular classes were the most preferable option among students (61.4%, 827/1,345) to get acquainted with the field, followed by internships (59.4%, 812/1,345), workshops (57%, 767/1,345), and social media (53.4%, 730/1,345). The main obstacles to pursue a global surgery career were lack of national opportunities (32%, 431/1,345) and adequate training (25.4%, 341/1,345). CONCLUSION: We outlined the most strategic pathways to raising awareness on global surgery among Brazilian medical students, providing relevant insights on its education in similar settings.

Gender Discrimination, Career Aspirations, and Access to Mentorship Among Medical Students in Brazil.

INTRODUCTION: Gender-based discrimination (GBD) creates a hostile environment that can affect medical students. Mentorship has been recognized as a mitigating factor for GBD. We aimed to investigate the impacts of GBD on career selection and well-being of medical students in Brazil and to explore access to mentorship among these students. METHODS: A cross-sectional study was performed using an anonymous survey in Portuguese. The survey was distributed in June 2021 to students enrolled in Brazilian medical schools. It contained 24 questions, including demographics, episodes of GBD experienced by responders and their impact on professional and personal life, and mentorship access. RESULTS: Of 953 respondents, 748 (78%) were cisgender women, 194 (20%) cisgender men, and 11 nonbinary (1%). Sixty-six percent (625/953) of students reported experiencing GBD, with cisgender women and nonbinary being more likely to experience it than cisgender men (P < 0.001). Responders who experiences GBD report moderate to severe impact on career satisfaction (40%, 250/624), safety (68%, 427/624), self-confidence (68%, 426/624), well-being (57%, 357/625), and burnout (62%, 389/625). Cisgender women were more likely to report these effects than men counterparts (P < 0.01). Only 21% of respondents (201/953) had mentors in their medical schools. CONCLUSIONS: Our findings demonstrate that GBD is widespread among Brazilian medical students affecting their personal and professional lives, and most of them do not have access to a mentor. There is an urgent need to increase access to mentors who could mitigate the adverse effects of GBD and help develop a diverse and inclusive medical workforce.

Defining Surgical Workforce Density Targets to Meet Child and Neonatal Mortality Rate Targets in the Age of the Sustainable Development Goals: A Global Cross-Sectional Study.

OBJECTIVES: To reduce preventable deaths of newborns and children, the United Nations set a target rate per 1000 live births of 12 for neonatal mortality (NMR) and 25 for under-5 mortality (U5MR). The purpose of this paper is to define the minimum surgical workforce needed to meet these targets and evaluate the relative impact of increasing surgeon, anesthesia, and obstetrician (SAO) density on reducing child mortality. METHODS: We conducted a cross-sectional study of 192 countries to define the association between surgical workforce density and U5MR as well as NMR using unadjusted and adjusted B-spline regression, adjusting for common non-surgical causes of childhood mortality. We used these models to estimate the minimum surgical workforce to meet the sustainable development goals (SDGs) for U5MR and NMR and marginal effects plots to determine over which range of SAO densities the largest impact is seen as countries scale-up SAO workforce. RESULTS: We found that increased SAO density is associated with decreased U5MR and NMR (P < 0.05), adjusting for common non-surgical causes of child mortality. A minimum SAO density of 10 providers per 100,000 population (95% CI: 7-13) is associated with an U5MR of < 25 per 1000 live births. A minimum SAO density of 12 (95% CI: 9-20) is associated with an NMR of < 12 per 1000 live births. The maximum decrease in U5MR, on the basis of our adjusted B-spline model, occurs from 0 to 20 SAO per 100,000 population. The maximum decrease in NMR based on our adjusted B-spline model occurs up from 0 to 18 SAO, with additional decrease seen up to 80 SAO. CONCLUSIONS: Scale-up of the surgical workforce to 12 SAO per 100,000 population may help health systems meet the SDG goals for childhood mortality rates. Increases in up to 80 SAO/100,000 continue to offer mortality benefit for neonates and would help to achieve the SDGs for neonatal mortality reduction.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital.

BACKGROUND: Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. MATERIAL AND METHODS: A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. RESULTS: A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. CONCLUSION: In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

Sex disparities in acute myocardial infarction care and outcomes.

AIM: We investigated sex-based and regional outcomes after contemporary percutaneous coronary intervention (PCI) with the Xience V stent in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: This patient level pooled analysis includes three multi-center, prospective post-market registries performed in the US, Japan, and China. A total of 1,938 patients treated with Xience V stents in the setting of AMI were enrolled. Compared to men, women had higher major adverse cardiac events (MACE) (14.1% vs. 9.8% P < 0.01, RR 1.4, 95% CI 1.1-1.4) and all-cause mortality (10% vs. 6.2% P < 0.01, RR 1.61, 95% CI 1.14-2.27) at one year, without any significant difference in device specific outcomes of target vessel failure (TVF). US patients compared to the patients from China and Japan had increased MACE (female: 18% vs. 7.1%, P = 0.0012, male: 15.7% vs. 4.1%, P < 0.0001). Multivariable analysis demonstrated that major bleeding was the strongest predictor of MACE (OR 10.51, 95%CI 4.01-27.50, P < 0.0001), MI (OR 4.26, 95%CI 1.37-13.29, P = 0.012), and all-cause death (OR 5.3, 95%CI 2.32-12.13, P < 0.0001). CONCLUSION: Women with AMI who underwent PCI with XIENCE DES have higher all-cause mortality at one year in compared to men. Region based outcomes demonstrated increased MACE among US patients compared to the patients from China and Japan. After adjusting for differences in demographics, major bleeding, rather than female sex, predicted the higher observed all-cause mortality.

Causes of Pediatric Deaths in Lusaka, Zambia: A Quantitative Geographic Information Systems Approach.

Background: While childhood mortality has been declining in Zambia, it remains high at 58 per 1000 live births. Importantly, many leading causes of mortality in Zambia are preventable. This study was conducted to identify clusters of childhood mortality, causes of death of recently deceased children, barriers to care, and risk factors for mortality in Lusaka, Zambia. Methods: This study was conducted as a prospective cohort study. Family members or lawfully authorized representatives (LARs) were interviewed when they came to pick up death certificates for recently deceased children from Lusaka Children's Hospital. Each interview included a verbal autopsy, determination of the child's location of residence, and collection of demographic information. Demographic data was also collected from a healthy control group. Quantitative Geographic Information Systems was used to visualize mortality and evaluate for clustering. Results: Leading primary causes of death included malnutrition (21%), complications of chronic illnesses (16%), and central nervous system infections (13%), while the leading barriers to care were cost (58%) and difficulties with travel (53%). Compared to controls, recently deceased children came from families with significantly lower incomes (1905 Kwacha vs. 2412 Kwacha, p = 0.03) and were significantly more likely to have a history of malnutrition (16.7% vs. 1.4%, p = 0.005). Mortality was clustered in two high-population density, low-income neighborhoods in Lusaka. Conclusions: Systems to reduce financial barriers to care and improve access to transportation could reduce childhood mortality in Lusaka. The aforementioned neighborhoods are ideal locations for public health interventions or improved healthcare services.

Online medical education: A student survey.

BACKGROUND: During COVID-19, medical schools transitioned to online learning as an emergency response to deliver their education programmes. This multi-country study compared the methods by which medical schools worldwide restructured the delivery of medical education during the pandemic. METHODS: This multi-country, cross-sectional study was performed using an internet-based survey distributed to medical students in multiple languages in November 2020. RESULTS: A total of 1,746 responses were received from 79 countries. Most respondents reported that their institution stopped in-person lectures, ranging from 74% in low-income countries (LICs) to 93% in upper-middle-income countries. While only 36% of respondents reported that their medical school used online learning before the pandemic, 93% reported using online learning after the pandemic started. Of students enrolled in clinical rotations, 89% reported that their rotations were paused during the pandemic. Online learning replaced in-person clinical rotations for 32% of respondents from LICs versus 55% from high-income countries (HICs). Forty-three per cent of students from LICs reported that their internet connection was insufficient for online learning, compared to 11% in HICs. CONCLUSIONS: The transition to online learning due to COVID-19 impacted medical education worldwide. However, this impact varied among countries of different income levels, with students from LICs and lower middle income countries facing greater challenges in accessing online medical education opportunities while in-person learning was halted. Specific policies and resources are needed to ensure equitable access to online learning for medical students in all countries, regardless of socioeconomic status.

Who gets burned in Brazil?

Burns are preventable injuries that still represent a relevant public health issue. The identification of risk factors might contribute to the development of specific preventive strategies. Data of patients admitted at the Hospital due to acute burn injuries from May 2017 to December 2019, was extracted manually from medical records. The population was analyzed descriptively, and differences between groups were tested using the appropriate statistical test. The study population consisted of 370 patients with burns admitted to the Hospital burn unit during the study period. The majority of the patients were males (257/370, 70%), median age was 33 (IQR:18-43), median TBSA% was 13 (IQR 6.35-21.5 and range 0-87.5%), and 54% of patients had full thickness burns (n=179). Children younger than 13 years old represented 17% of the study population (n=63), 60% of them were boys (n= 38), and scalds was the predominant mechanism of burn injury (n= 45). No children died, however 10% of adults did (n= 31). Self-inflicted burns were observed in 16 adults (5%), of whom 6 (38%) died during admission, however self-inflicted burns were not observed in children. Psychiatric disorders and substance misuse were frequent in this subgroup. White adults male from urban areas who had not completed primary school degree were the major risk group for burns. Smoking and alcohol misuse were the most frequent comorbidities. Accidental domestic flame burns were the predominant injuries in the adult population and scalds in the pediatric.

The impact of COVID-19 on routine pediatric vaccination delivery in Brazil.

INTRODUCTION: Childhood vaccination rates have decreased significantly during the COVID-19 pandemic. The Brazilian immunization program, Programa Nacional de Imunização (PNI), is a model effort, achieving immunization rates comparable to high-income countries. This study aimed to evaluate the impact of the COVID-19 pandemic in pediatric vaccinations administered by the PNI, as a proxy of adherence to vaccinations during 2020. METHODS: Data on the number of vaccines administered to children under 10 years of age nationally and in each of Brazil's five regions were extracted from Brazil's federal health delivery database. Population adjusted monthly vaccination rates from 2015 through 2019 were determined, and autoregressive integrated moving average (ARIMA) models were used to forecast expected vaccinated rates in 2020. We compared the forecasts to reported vaccine administrations to assess adequacy of pediatric vaccine delivery during the COVID-19 pandemic. RESULTS: From January 2015 to February 2020, the average rate of vaccine administration to children was 53.4 per 100,000. After February 2020, this rate decreased to 50.4, a 9.4% drop compared to 2019 and fell outside of forecasted ranges in December 2020. In Brazil's poorest region, the North, vaccine delivery fell outside of the forecasted ranges earlier in 2020 but subsequently rebounded, meeting expected targets by the end of 2020. However, in Brazil's wealthiest South and Southeast regions, initial vaccine delivery fell and remained well below forecasted rates through the end of 2020. CONCLUSION: In Brazil, despite a model national pediatric vaccination program with an over 95% national coverage, vaccination rates decreased during the COVID-19 pandemic. Coordinated governmental efforts have ameliorated some of the decrease, but more efforts are needed to ensure continued protection from preventable communicable diseases for children globally.

Longitudinal Cognitive Outcomes in Children With HIV in Zambia: 2-Year Outcomes From the HIV-Associated Neurocognitive Disorders in Zambia (HANDZ) Study.

OBJECTIVE: To describe longitudinal outcomes and predictors of cognitive outcomes in children with HIV in Zambia. BACKGROUND: Multiple studies have shown that children with HIV are at risk for impaired cognition. However, there are limited data on longitudinal cognitive outcomes in children with HIV. METHODS: We conducted a prospective cohort study of 208 perinatally infected children with HIV ages 8-17 years, all treated with antiretroviral therapy, and 208 HIV-exposed uninfected controls. Participants were followed for 2 years. Cognition was assessed with a custom NIH Toolbox Cognition Battery, and tests were combined to generate a Summary Cognition Score (SCS). The contribution of potential risk factors to outcomes was explored using regression models and group-based trajectory modeling. RESULTS: HIV was strongly associated with lower SCS at baseline [ß-14, 95% confidence interval (CI): -20 to -7, P < 0.001]. Change scores over time were similar between groups, but poorer average performance in children with HIV persisted at the 2-year follow-up visit (adjusted ß = -11, 95% CI: -22 to -0.3, P = 0.04). Other than HIV, the strongest predictors of baseline SCS included socioeconomic status index (ß =3, 95% CI: 1, 5, P = 0.004), history of growth stunting (ß=-14, 95% CI: -23 to -6, P = 0.001), history of CD4 count below 200 (ß = -19, 95% CI: -35 to -2, P = 0.02), and history of World Health Organization stage 4 disease (ß = -10, 95% CI: -19 to -0.2, P = 0.04). In the group-based trajectory model, HIV+ status predicted membership in the lowest performing trajectory group (odds ratio 2.5, 95% CI: 1.2 to 5.1, P = 0.01). CONCLUSIONS: Children with HIV are at risk of poor cognitive outcomes, despite chronic treatment with antiretroviral therapy.

Is authorship by women in Brazilian academic surgery increasing? A five-year retrospective analysis.

Women remain underrepresented in 80% of Brazilian surgical specialties, however, women representation within the Brazilian academic surgical literature remains unknown. This study aims to evaluate the gender distribution of first and last authors in Brazilian surgical journals. All publications between 2015 and 2019 from the five Brazilian surgical journals with the highest impact factor were reviewed. The first and last authors' names were extracted from each article and a predictive algorithm was used to classify the gender of each author. Authors were further classified by surgical field and geographic region to investigate patterns of female authorship among journals, specialties, and region over the study period. Multivariable logistic regression was then used to identify factors independently associated with female authorship. 1844 articles were analyzed; 23% (426/1844) articles had female first authors, and 20% (348/1748) had female last authors. Acta Cirúrgica Brasileira was observed to have the highest rates for both first and last female authors (37%, 138/371; 26%, 95/370)) and Revista Brasileira de Ortopedia (9%, 48/542; 10%, 54/522) had the lowest rates. Papers with a woman senior author were twice as likely to have a woman first author (OR 1.98, 95% CI 1.51-2.58, p≤0.01). Women's representation in medicine is increasing in Brazil, yet women remain underrepresented as the first and last authors in the Brazilian surgical literature. Our results highlight the importance of senior women mentorship in academic surgery and demonstrate that promoting female surgeon senior authorship through academic and financial support will positively impact the number of female first authors.

Use of geospatial analysis for priority setting in surgical system investment in Guatemala.

Background: Two-hour and 30 min travel times to a hospital capable of performing emergency general surgery and cesarean section are benchmarks for timely surgical access. This study aimed to estimate the population of Guatemala with timely access to surgical care and identify existing hospitals where the expansion of surgical services would increase access. Methods: The World Federation of Societies of Anaesthesiologists (WFSA) Anesthesia Facility Assessment Tool (AFAT) previously identified 37 public Guatemalan hospitals that provide surgical care. Nine additional public non-surgical hospitals were also identified. Geospatial analysis was performed to estimate walking and driving geographic access to all 46 hospitals. We calculated the potential increase in access that would accompany the expansion of surgical services at each of the nine non-surgical hospitals. Findings: The percentage of the population with walking access to a surgical hospital within 30 min, 1 h, and 2 h are 5·1%, 12·9%, and 27·3%, respectively. The percentage of people within 30 min, 1 h, and 2 h driving times are 27·3%, 41·1%, and 53·1%, respectively. The median percentage of the population within each of Guatemala's 22 administrative departments with 2 h walking access was 19·0% [IQR 14·1-30·7] and 2 h driving access was 52·4% [IQR 30·5-62·8]. Expansion of surgical care at existing public Guatemalan hospitals in Guatemala would result in a minimal increase in overall geographic access compared to current availability. Interpretation: While Guatemala provides universal health coverage, geographic access to surgical care remains inadequate. Geospatial mapping and survey data work synergistically to assess surgical system strength and identify gaps in geographic access to essential surgical care. Funding: None.

Socioeconomic Status and Cognitive Function in Children With HIV: Evidence From the HIV-Associated Neurocognitive Disorders in Zambia (HANDZ) Study.

BACKGROUND: Multiple previous studies have identified a detrimental effect of pediatric HIV on cognitive function. Socioeconomic status (SES) is one of the strongest predictors of cognitive performance and may affect the relationship between HIV and cognition. METHODS: As part of the ongoing HIV-Associated Neurocognitive Disorders in Zambia (HANDZ) study, a prospective cohort study, we recruited 208 participants with HIV and 208 HIV-exposed uninfected controls, all aged 8-17 years. A standardized questionnaire was administered to assess SES, and all participants had comprehensive neuropsychological testing. An NPZ8 score was derived as a summary measure of cognitive function. Logistic regression and linear regression were used to model the relationship between SES and cognitive function, and mediation analysis was used to identify specific pathways by which SES may affect cognition. RESULTS: Children with HIV performed significantly worse on a composite measure of cognitive function (NPZ8 score -0.19 vs. 0.22, P < 0.001) and were more likely to have cognitive impairment (33% vs. 19%, P = 0.001). Higher SES was associated with reduced risk of cognitive impairment (odds ratio 0.8, 95% confidence interval: 0.75-0.92, P < 0.001) in both groups, with similar effects in children with HIV and HIV-exposed uninfected groups. SES was more strongly correlated with NPZ8 score in children with HIV than in uninfected controls (Pearson's R 0.39 vs. 0.28), but predicted NPZ8 in both groups. Mediation analysis suggested that the effect of SES on cognition was most strongly mediated through malnutrition. CONCLUSIONS: Cognitive function is strongly correlated with SES in children with HIV, suggesting a synergistic effect of HIV and poverty on cognitive function.

Timely Access to Neurosurgical Care in the Caribbean Using Geospatial Analysis.

BACKGROUND: Access to timely neurosurgical care in particular remains limited worldwide, and is associated with increased morbidity and mortality, a decrease in overall life expectancy, and catastrophic economic costs. To date, access to neurosurgical care has not been completely studied and reported in the Caribbean neurosurgical literature. In this study, we aim to understand the geographic distribution of hospital facilities with neurosurgical capacity among the CARICOM member states to determine timely access to neurosurgical care. METHODS: We assessed geographical access to facilities capable of providing neurosurgical care in the Caribbean. The GPS coordinates of the hospitals that provide neurosurgical care were identified using street addresses and satellite imaging from Google Maps. Facilities with neurosurgical care were mapped in ArcGIS Pro (Version 2.6.0). using Manhattan distance. We identified the area around each facility and stratified by 30- minute, 1-hour, 2-hour, and 4-hour geographic driving intervals. RESULTS: A total of 16 hospitals were identified as providing neurosurgical care in the Caribbean. Our results suggest that 14 million people (76% of the population) had 4-hour geographic access to a facility capable of providing neurosurgical care. In addition, 7 million people (40% of the population) had 2-hour geographical access to neurosurgical care. CONCLUSIONS: Timely access to care is an important tenet of global neurosurgery. We found that 3.5 million Caribbean residents are outside of the access zone to neurosurgical capacity. Public health advocates, governments, providers, and patients should be aware of the inequity in access to neurosurgical care and should collectively work to close the gap.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study.

BACKGROUND: The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. METHODS: Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. FINDINGS: Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663-1,523,995) total operations, 161,321 (95%CI 37,468-395,478) emergent operations, and 928,758 (95%CI 675,202-1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. INTERPRETATION: Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Neighborhood-Based Socioeconomic Determinants of Cognitive Impairment in Zambian Children With HIV: A Quantitative Geographic Information Systems Approach.

BACKGROUND: Place-based inequalities, such as exposure to violence and access to nutritious food and clean water, may contribute to human immunodeficiency virus (HIV)-associated cognitive impairment. In this study, we investigated neighborhood effects on cognition in children and adolescents with HIV in Lusaka, Zambia. METHODS: We conducted a prospective cohort study of 208 children with perinatally acquired HIV (ages 8-17) and 208 HIV-exposed uninfected controls. Participants underwent neuropsychological testing and interviews assessing socioeconomic status. Geographic regions with clusters of participants with HIV and cognitive impairment were identified using quantitative geographic information systems (QGIS) and SaTScan. Associations between location of residence and cognitive function were evaluated in bivariable and multivariable regression models. Mediation analysis was performed to assess direct and indirect effects of location of the residence on cognitive impairment. RESULTS: Residence in Chawama, one of the poorest neighborhoods in Lusaka, was significantly associated with cognitive impairment in participants with HIV (odds ratio 2.9; P = .005) and remained significant in a multivariable regression model controlling for potential confounders. Mediation analysis found that 46% of the cognitive effects of residence in Chawama were explained by higher rates of malnutrition, lower school attendance, and poorer self-reported health. CONCLUSIONS: Place-based socioeconomic inequality contributes to cognitive impairment in Zambian children and adolescents with HIV. Neighborhood effects may be mediated by concentrated poverty, malnutrition, limited access to education and health care, and other yet unknown environmental factors that may be potentially modifiable.