Browsing by Author "Ozgediz, Doruk"

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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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    Best Buy in Public Health or Luxury Expense?: The Cost-effectiveness of a Pediatric Operating Room in Uganda From the Societal Perspective
    (Annals of surgery, 2021) Yap, Ava; Cheung, Maija; Muzira, Arlene; Healy, James; Kakembo, Nasser; Kisa, Phyllis; Cunningham, David; Youngson, George; Sekabira, John; Yaesoubi, Reza; Ozgediz, Doruk
    To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective.Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children.In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%.In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country’s gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses.Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.
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    Burden of Emergency Pediatric Surgical Procedures on Surgical Capacity in Uganda: A New Metric for Health System Performance
    (Surgery, 2020) Grabski, David F.; Kakembo, Nasser; Situma, Martin; Cheung, Maija; Shikanda, Anne; Okello, Innocent; Kisa, Phyllis; Muzira, Arlene; Sekabira, John; Ozgediz, Doruk
    The significant burden of emergency operations in low- and middle-income countries can overwhelm surgical capacity leading to a backlog of elective surgical cases. The purpose of this investigation was to determine the burden of emergency procedures on pediatric surgical capacity in Uganda and to determine health metrics that capture surgical backlog and effective coverage of children’s surgical disease in low- and middle-income countries.We reviewed 2 independent and prospectively collected databases on pediatric surgical admissions at Mulago National Referral Hospital and Mbarara Regional Referral Hospital in Uganda. Pediatric surgical patients admitted at either hospital between October 2015 to June 2017 were included. Our primary outcome was the distribution of surgical acuity and associated mortality.A combined total of 1,930 patients were treated at the two hospitals, and 1,110 surgical procedures were performed. There were 571 emergency cases (51.6%), 108 urgent cases (9.7%), and 429 elective cases (38.6%). Overall mortality correlated with surgical acuity. Emergency intestinal diversions for colorectal congenital malformations (anorectal malformations and Hirschsprung’s disease) to elective definitive repair was 3:1. Additionally, 30% of inguinal hernias were incarcerated or strangulated at time of repair.Emergency and urgent operations utilize the majority of operative resources for pediatric surgery groups in low- and middle-income countries, leading to a backlog of complex congenital procedures. We propose the ratio of emergency diversion to elective repair of colorectal congenital malformations and the ratio of emergency to elective repair of inguinal hernias as effective health metrics to track this backlog. Surgical capacity for pediatric conditions should be increased in Uganda to prevent a backlog of elective cases.
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    Colonic Duplication with Recto-Urethral Fistula: Elusive Diagnosis and Successful Treatment in a Resource-Limited Setting
    (Journal of Pediatric Surgery Case Reports, 2014) Kisa, Phyllis; Kakembo, Nasser; Ozgediz, Doruk; Sekabira, John
    A 3-year-old Ugandan boy presented with 18 months of constipation and 12 months of pneumaturia and fecaluria. Physical exam revealed abdominal distension and a palpable mass anterior to the rectum. Previous contrast enema had been non-diagnostic, and a voiding cystourethrogram (VCUG) had confirmed a recto-urethral fistula. After surgical evaluation, a computed tomography (CT) scan suggested colonic duplication, and a laparotomy was performed for rapidly progressive bowel obstruction. A tubular colonic duplication with fecal impaction was found, necessitating fecal disimpaction and a double divided colostomy. Two months later at re-laparotomy, the septum between the duplicated colonic lumens was found to extend proximally to the mid transverse colon and distally to the upper rectum, and was divided. No urethral fistula was identified, and the colostomy was recreated. At a third operation, the colostomy was reversed. The patient is well at one-year follow up, without evidence of recurrent fistula or stricture. This case shows that colonic duplication in children can be an elusive diagnosis. Often, a variety of radiographic studies may be needed and may be difficult to interpret. In cases with colo-urinary fistula, the fistula may respond to fecal diversion without requiring operative repair. Management in a resource-limited setting can still yield positive outcome.
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    Colonic Polyposis in a 15 Year-Old Boy: Challenges and Lessons from a Rural Resource-Poor Area
    (Annals of Medicine and Surgery, 2016) Kakembo, Nasser; Kisa, Phyllis; Ozgediz, Doruk; Sekabira, John
    Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges.This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon.In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access.Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.
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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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    A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda
    (Surgery, 2018) Yap, Ava; Muzira, Arlene; Cheung, Maija; Healy, James; Kakembo, Nasser; Kisa, Phyllis; Cunningham, David; Youngson, George; Sekabira, John; Yaesoubi, Reza; Ozgediz, Doruk
    This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age.A simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach.A pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288–6,606) and cost $41,182/year (UI 40,539–41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses.The construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.
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    Design, implementation and long-term follow-up of a context specific trauma training course in Uganda: Lessons learned and future directions
    (The American Journal of Surgery, 2020) Ullrich, Sarah J.; Kilyewala, Cathy; Lipnick, Michael S.; Cheung, Maija; Namugga, Martha; Muwanguzi, Peter; DeWane, Michael P.; Muzira, Arlene; Tumukunde, Janat; Kabagambe, Monica; Kebba, Naomi; Galukande, Moses; Mabweijano, Jacqueline; Ozgediz, Doruk
    The Kampala Advanced Trauma Course (KATC) was developed in 2007 due to a locally identified need for an advanced trauma training curriculum for the resource-constrained setting. We describe the design, implementation and evaluation of the course.The course has been delivered to over 1,000 interns rotating through surgery at Mulago National Referral Hospital. Participants from 2013 to 2016 were surveyed after completion of the course.The KATC was developed with local faculty and includes didactic and simulation modules. Over 50% of survey respondents reported feeling confident performing and teaching 7 of 11 course skills and felt the most relevant skill was airway management(30.2%). Participants felt least confident managing head trauma(26.4%). Lack of equipment(52.8%) was identified as the most common barrier to providing trauma care.Providers are confident with most skill sets after taking the KATC. Minimal dependence on instructors from high-income countries has kept the course sustainable and maximized local relevance.
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    Development of an Operative Trauma Course in Ugandad - A Report of a Three-Year Experience
    (Journal of Surgical Research, 2020) Ullrich, Sarah J.; DeWane, Michael P.; Cheung, Maija; Fleming, Matthew; Namugga, Martha M.; Kurigamba, Gideon; Kabuye, Ronald; Mabweijano, Jackie; Galukande, Moses; Ozgediz, Doruk; Pei, Kevin Y.
    Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice. Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater. Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%). The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training.
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    Disparity in access and Outcomes for Emergency Neonatal Surgery: Intestinal Atresia in Kampala, Uganda
    (Pediatric Surgery International, 2017) Cairo, Sarah; Kakembo, Nasser; Kisa, Phyllis; Muzira, Arlene; Cheung, Maija; Healy, James; Ozgediz, Doruk; Sekabira, John
    Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings.A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012–2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease.Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs’ unmet.Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone.
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    Epidemiology and Mortality of Pediatric Surgical Conditions: Insights from aTertiary Center in Uganda
    (Pediatric Surgery International, 2019) Cheung, Maija; Kakembo, Nasser; Rizgar, Nensi; Grabski, David; Ullrich, Sarah; Muzira, Arlene; Kisa, Phyllis; Sekabira, John; Ozgediz, Doruk
    The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited.Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016.2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung’s, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%).There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.
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    Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy
    (International journal of emergency medicine, 2010) Hsia, Renee Y.; Ozgediz, Doruk; Mutto, Milton; Jayaraman, Sudha; Kyamanywa, Patrick; Kobusingye, Olive C.
    Despite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality. Aim To estimate the epidemiology of the injury seen in patients presenting to the government hospital inKampala, the capital city of Uganda. Methods A secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005. Results From 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance. Conclusions Road traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.
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    Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries
    (PLoS Medicine, 2010) Galukande, Moses; Schreeb, Johan von; Wladis, Andreas; Mbembati, Naboth; Miranda, Helder de; Kruk, Margaret E.; Luboga, Sam; Matovu, Alphonsus; McCord, Colin; Ndao-Brumblay, S. Khady; Ozgediz, Doruk; Rockers, Peter C.; Quinones, Ana Roman; Vaz12, Fernando; Debas, Haile T.; Macfarlane, Sarah B.
    Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub- Saharan African countries. Methods and Findings: In a retrospective descriptive study, field data were collected from eight district hospitals in Uganda, Tanzania, and Mozambique using a standardized form and interviews with key informants. Overall, the scope of surgical procedures performed was narrow and included mainly essential and life-saving emergency procedures. Surgical output varied across hospitals from five to 45 major procedures/10,000 people. Obstetric operations were most common and included cesarean sections and uterine evacuations. Hernia repair and wound care accounted for 65% of general surgical procedures. The number of beds in the studied hospitals ranged from 0.2 to 1.0 per 1,000 population. Conclusion: The findings of this study clearly indicate low levels of surgical care provision at the district level for the hospitals studied. The extent to which this translates into unmet need remains unknown although the very low proportions of live births in the catchment areas of these eight hospitals that are born by cesarean section suggest that there is a substantial unmet need for surgical services. The district hospital in the current health system in sub-Saharan Africa lends itself to feasible integration of essential surgery into the spectrum of comprehensive primary care services. It is therefore critical that the surgical capacity of the district hospital is significantly expanded; this will result in sustainable preventable morbidity and mortality.
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    From Procedure to Poverty: Out-of-Pocket and Catastrophic Expenditure for Pediatric Surgery in Uganda
    (Journal of Surgical Research, 2018) Yap, Ava; Cheung, Maija; Kakembo, Nasser; Kisa, Phyllis; Muzira, Arlene; Sekabira, John; Ozgediz, Doruk
    Financial protection from catastrophic health care expenditure (CHE) and patient out-of-pocket (OOP) spending are key indicators for sustainable surgical delivery. We aimed to calculate these metrics for a hospital stay requiring surgery in Uganda's pediatric population.A survey was administered to family members of postoperative patients in the pediatric surgical ward at Mulago Hospital. Cost categories included direct medical costs, direct nonmedical costs, indirect costs, plus money borrowed and items sold to pay for the hospital stay. CHE was defined as spending greater than 10% of annual household expenditure. Costs were reported in Ugandan shillings and US dollars.One hundred and thirty-two patient families were surveyed between November 2016 and April 2017. Median direct costs were $27.55 (IQR 18.73-183.69) for diagnostics, $18.36 (IQR 9.52-41.33) for medications, $26.63 (IQR 9.19-45.92) for transportation, and $32.60 (IQR 12.85-64.29) for food and lodging. Forty-four percent of respondents were employed, and median indirect cost from productivity loss was $95.52 (IQR 55.10-243.38). Eighteen percent (16/87) borrowed money, and 9% (8/87) sold possessions to pay for the hospital stay. Total median OOP cost for patient families per hospital stay was $150.62 (IQR 65.21-339.82). Sixteen percent (21/132) of families incurred CHE from direct costs, and the proportion rose to 27% (32/132) when indirect cost was included.Although pediatric surgical services in Uganda are formally provided for free by the public sector, families accrue substantial OOP expenditure and almost a third of households incur CHE for a pediatric surgical procedure. This study suggests that broader financial protection must be established to meet Sustainable Development Goal targets.
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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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    Global children’s surgery: recent advances and future directions
    (Current opinion in pediatrics, 2019) Ullrich, Sarah; Kisa, Phyllis; Ozgediz, Doruk
    Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery.Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.
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    Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey
    (PLoS Med, 2010) Kruk, Margaret E.; Wladis, Andreas; Mbembati, Naboth; Ndao-Brumblay, S. Khady; Hsia, Renee Y.; Galukande, Moses; Luboga, Sam; Matovu, Alphonsus; Miranda, Helder de; Ozgediz, Doruk; Roman Quinones, Ana; Rockers, Peter C.; Schreeb, Johan von; Vaz, Fernando; Debas, Haile T.; Macfarlane, Sarah B.
    There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries. Methods and Findings: We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals. Conclusion: African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas.
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    Implementation of a Contextually Appropriate Pediatric Emergency Surgical Care Course in Uganda
    (Journal of Pediatric Surgery, 2021) Ullrich, Sarah; Kisa, Phyllis; Ruzgar, Nensi; Okello, Innocent; Oyania, Felix; Kayima, Peter; Kakembo, Nasser; Sekabira, John; Situma, Martin; Ozgediz, Doruk
    Low- and middle-income countries like Uganda face a severe shortage of pediatric surgeons. Most children with a surgical emergency are treated by nonspecialist rural providers. We describe the design and implementation of a locally driven, pilot pediatric emergency surgical care course to strengthen skills of these providers. This is the first description of such a course in the current literature.The course was delivered three times from 2018 to 2019. Modules include perioperative management, neonatal emergencies, intestinal emergencies, and trauma. A baseline needs assessment survey was administered. Participants in the second and third courses also took pre and postcourse knowledge-based tests.Forty-five providers representing multiple cadres participated. Participants most commonly perform hernia/hydrocele repair (17% adjusted rating) in their current practice and are least comfortable managing cleft lip and palate (mean Likert score 1.4 ± 0.9). Equipment shortage was identified as the most significant challenge to delivering pediatric surgical care (24%). Scores on the knowledge tests improved significantly from pre- (55.4% ± 22.4%) to postcourse (71.9% ± 14.0%, p < 0.0001).Nonspecialist clinicians are essential to the pediatric surgical workforce in LMICs. Short, targeted training courses can increase provider knowledge about the management of surgical emergencies. The course has spurred local surgical outreach initiatives. Further implementation studies are needed to evaluate the impact of the training.
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    Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group
    (PLoS Med, 2009) Luboga, Sam; Macfarlane, Sarah B.; Schreeb, Johan von; Kruk, Margaret E.; Cherian, Meena N.; Bergstrom, Staffan; Bossyns, Paul B. M.; Denerville, Ernest; Dovlo, Delanyo; Galukande, Moses; Hsia, Renee Y.; Jayaraman, Sudha P.; Lubbock, Lindsey A.; Mock, Charles; Ozgediz, Doruk; Sekimpi, Patrick; Wladis, Andreas; Zakariah, Ahmed; Babadi Dade, Nameoua; Donkor, Peter; Kabutu Gatumbu, Jane; Hoekman, Patrick; IJsselmuiden, Carel B.; Jamison, Dean T.; Jessani, Nasreen; Jiskoot, Peter; Kakande, Ignatius; Mabweijano, Jacqueline R.; Mbembati, Naboth; McCord, Colin; Mijumbi, Cephas; Miranda, Helder de; Mkony, Charles A.; Mocumbi, Pascoal; Ndihokubwayo, Jean Bosco; Ngueumachi, Pierre; Ogbaselassie, Gebreamlak; Okitombahe, Evariste Lodi; Tidiane Toure, Cheikh; Vaz, Fernando; Zikusooka, Charlotte M.; Debas, Haile T.
    In sub-Saharan Africa, only 46% of births are attended by skilled personnel, compared to 96% in Europe (according to data for the African Region of the World Health Organization [WHO] from 2000 to 2008 [1]). In 2005, slightly over one quarter of a million women died from complications of childbirth [1]; most of these deaths could have been avoided by providing women with access to basic obstetric care and obstetric surgical care. On average, across sub- Saharan Africa, a population of 10,000 is served by two doctors and 11 nursing and midwifery personnel, compared to 32 and 79 respectively serving the same number of people in Europe (WHO data 2000–2007 [1]). A child born in sub- Saharan Africa in 2007 could expect to live only 52 years, which is 22 years less than its European counterpart [1].
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    Key Aspects of Health Policy Development to Improve Surgical Services in Uganda
    (World journal of surgery, 2010) Luboga, Sam; Galukande, Moses; Mabweijano, Jacqueline; Ozgediz, Doruk; Jayaraman, Sudha
    Recently, surgical services have been gaining greater attention as an integral part of public health in lowincome countries due to the significant volume and burden of surgical conditions, growing evidence of the cost effectiveness of surgical intervention, and global disparities in surgical care. Nonetheless, there has been limited discussion of the key aspects of health policy related to surgical services in low-income countries. Uganda, like other low-income sub-Saharan African countries, bears a heavy burden of surgical conditions with low surgical output in health facilities and significant unmet need for surgical care. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala, Uganda, in May 2008 to develop a road map of key policy actions that would improve surgical services at the national level. The group identified a list of health policy priorities to improve surgical services in Uganda. The priorities were classified into three areas: (1) human resources, (2) health systems, and (3) research and advocacy. This article is a critical discussion of these health policy priorities with references to recent literature. This was the first such multidisciplinary meeting in Uganda with a focus on surgical services and its output may have relevance to health policy development in other low income countries planning to improve delivery of surgical services