Browsing by Author "Langer, Monica"

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    Access to Pediatric Surgery Delivered by General Surgeons and Anesthesia Providers in Uganda: Results from 2 Rural Regional Hospitals
    (Surgery, 2021) Grabski, David F.; Ajiko, Margaret; Kayima, Peter; Ruzgar, Nensi; Nyeko, David; Fitzgerald, Tamara N.; Langer, Monica; Cheung, Maija; Cigliano, Bruno; D’Agostino, Sergio; Baird, Robert; Duffy, Damian; Tumukunde, Janat; Nabukenya, Mary; Phyllis Kisa, Phyllis; Ogwang, Martin; Sekabira, John; Kakembo, Nasser; Ozgediz, Doruk
    Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children’s surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.Two years of a prospective clinical database of children’s surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.
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    Comparison of Ugandan and North American Pediatric Surgery Fellows’ Operative Experience: Opportunities for Global Training Exchange
    (Journal of Surgical Education, 2020) Reed, Christopher R.; Commander, Sarah J.; Sekabira, John; Kisa, Phyllis; Kakembo, Nasser; Wesonga, Anne; Langer, Monica; Villanova, Gustavo A.; Ozgediz, Doruk; Fitzgerald, Tamara N.
    North American pediatric surgery training programs vary in exposure to index cases, while controversy exists regarding fellow participation in global surgery rotations. We aimed to compare the case logs of graduating North American pediatric surgery fellows with graduating Ugandan pediatric surgery fellows.The pediatric surgery training program at a regional Ugandan hospital hosts a collaboration between Ugandan and North American attending pediatric surgeons. Fellow case logs were compared to the Accreditation Council for Graduate Medical Education Pediatric Surgery Case Log 2018 to 19 National Data Report.Mulago National Referral Hospital in Kampala, Uganda; and pediatric surgery training programs in the United States and Canada.Three Ugandan fellows completed training and submitted case logs between 2011 and 2019 with a mean of 782.3 index cases, compared to the mean 753 cases in North America. Ugandan fellows performed more procedures for biliary atresia (6.7 versus 4), Wilm's tumor (23.7 versus 5.7), anorectal malformation (45 versus 15.7), and inguinal hernia (158.7 versus 76.8). North American fellows performed more central line procedures (73.7 versus 30.7), cholecystectomies (27.3 versus 3), extracorporeal membrane oxygenation cannulations (16 versus 1), and congenital diaphragmatic hernia repairs (16.5 versus 5.3). All cases in Uganda were performed without laparoscopy.Ugandan fellows have access to many index cases. In contrast, North American trainees have more training in laparoscopy and cases requiring critical care. Properly orchestrated exchange rotations may improve education for all trainees, and subsequently improve patient care.
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    Gastroschisis in Uganda: Opportunities for improved survival
    (Journal of pediatric surgery, 2016) Wesonga, Anne S.; Fitzgerald, Tamara N.; Kabuye, Ronald; Kirunda, Samuel; Langer, Monica; Kakembo, Nasser; Ozgediz, Doruk; Sekabira, John
    Neonatal mortality from gastroschisis in sub-Saharan Africa is high, while in high-income countries, mortality is less than 5%. The purpose of this study was to describe the maternal and neonatal characteristics of gastroschisis in Uganda, estimate the mortality and elucidate opportunities for intervention. An ethics-approved, prospective cohort study was conducted over a one-year period. All babies presenting with gastroschisis in Mulago Hospital in Kampala, Uganda were enrolled and followed up to 30days. Univariate and descriptive statistical analyses were performed on demographic, maternal, perinatal, and clinical outcome data. 42 babies with gastroschisis presented during the study period. Mortality was 98% (n=41). Maternal characteristics demonstrate a mean maternal age of 21.8 (±3.9) years, 40% (n=15) were primiparous, and fewer than 10% (n=4) of mothers reported a history of alcohol use, and all denied cigarette smoking and NSAID use. Despite 93% (n=39) of mothers receiving prenatal care and 24% (n=10) a prenatal ultrasound, correct prenatal diagnosis was 2% (n=1). Perinatal data show that 81% of deliveries occurred in a health facility. The majority of babies (58%) arrived at Mulago Hospital within 12h of birth, however 52% were breastfeeding, 53% did not have intravenous access and only 19% had adequate bowel protection in place. Four patients (9%) arrived with gangrenous bowel. One patient, the only survivor, had primary closure. Average time to death was 4.8days [range<1 to 14days]. The mortality of gastroschisis in Uganda is alarmingly high. Improving prenatal diagnosis and postnatal care of babies in a tertiary center may improve outcome.
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    Outcomes and Unmet Need for Neonatal Surgery in a Resource-Limited Environment: Estimates of Global Health Disparities from Kampala, Uganda
    (Journal of pediatric surgery, 2014) Badrinath, Raghav; Kakembo, Nasser; Kisa, Phyllis; Langer, Monica; Ozgediz, Doruk; Sekabira, John
    Reported outcomes of neonatal surgery in low-income countries (LICs) are poor. We examined epidemiology, outcomes, and met and unmet need of neonatal surgical diseases in Uganda. Pediatric general surgical admissions and consults from January 1, 2012, to December 31, 2012, at a national referral center in Uganda were analyzed using a prospective database. Outcomes were compared with high-income countries (HICs), and met and unmet need was estimated using burden of disease metrics (disability-adjusted life years or DALYs).23% (167/724) of patients were neonates, and 68% of these survived. Median age of presentation was 5days, and 53% underwent surgery. 88% survived postoperatively, while 55% died without surgery (p<0.001). Gastroschisis carried the highest mortality (100%) and the greatest mortality disparity with HICs. An estimated 5072 DALYs were averted by neonatal surgery in Uganda (met need), with 140,154 potentially avertable (unmet need). Approximately 3.5% of the need for neonatal surgery is met by the health system.More than two thirds of surgical neonates survived despite late presentation and lack of critical care. Epidemiology and outcomes differ greatly with HICs. A high burden of hidden mortality exists, and only a negligible fraction of the population need for neonatal surgery is met by health services.
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    Pediatric Surgery as an Essential Component of Global Child Health
    (In Seminars in pediatric surgery, 2016) Ozgediz, Doruk; Langer, Monica; Kisa, Phyllis; Poenaru, Dan
    Recent initiatives in global health have emphasized universal coverage of essential health services. Surgical conditions play a critical role in child health in resource-poor areas. This article discusses (1) the spectrum of pediatric surgical conditions and their treatment; (2) relevance to recent advances in global surgery; (3) challenges to the prioritization of surgical care within child health, and possible solutions; (4) a case example from a resource-poor area (Uganda) illustrating some of these concepts; and (5) important child health initiatives with which surgical services should be integrated. Pediatric surgery providers must lead the effort to prioritize children׳s surgery in health systems development.
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    Pediatric Surgical Camps as one Model of Global Surgical Partnership: A Way Forward
    (Journal of Pediatric Surgery, 2014) Blair, Geoffrey K.; Duffy, Damian; Male, Doreen Birabwa; Sekabira, John; Reimer, Eleanor; Koyle, Martin; Hudson, Guy R.; Stanger, Jennifer; Langer, Monica; Eeson, Gareth; Gan, Heng; McLean, Sean; Kanaroglou, Nikki; Kisa, Phyllis; Kakembo, Nasser; Lidstone, Katherine
    A uniquely Ugandan method of holding surgical “camps” has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership.We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery.Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian–Ugandan pediatric surgery teaching alliance.Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.
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    The SocioeconomicImpact of a Pediatric Ostomy in Uganda: a pilot study
    (Pediatric surgery international, 2018) Muzira, Arlene; Kakembo, Nasser; Kisa, Phyllis; Langer, Monica; sekabira, John; Ozgediz, Doruk; Fitzgerald, Tamara N.
    Multiple pediatric surgical conditions require ostomies in low–middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung’s disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.During the period of January 2012–December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial. The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.