Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer

Background
There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries.

Methods
This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS).

Results
Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS.

Conclusion
While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Piloting a Faculty Development Program in a Rural Haitian Teaching Hospital

Background: Faculty development for nurse and physician educators has a limited evidence base in high income countries, and very little research from low- and middle-income countries. Health professions educators in many global settings do not receive training on how to educate effectively.

Objective: To pilot and assess a faculty development program aimed at nurse and physician educators at a teaching hospital in rural Haiti.

Methods: We developed a program covering a total of 22 topics in health professions education, including applied learning theory as well as nurse and physician targeted topics. We assessed impact through participant assessment of personal growth, participant evaluation of the program, knowledge testing pre and post program, and structured observations of program participants providing teaching during the program.

Findings: Nineteen out of 37 participants completed the program. While participant reviews were uniformly positive, a pre- and post-test on general educational topics showed no significant change, and the effort to institute observation and feedback of teaching did not succeed.

Conclusions: Our project showcases some benefits of faculty development, while also demonstrating the challenges of instituting faculty development in situations where participants have limited time and resources. We suspect more benefits may emerge as the program evolves to fit the learners and setting

The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study

Background
In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes.

Methods
We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth).

Results
Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (β = − 0.070; 95% CI: − 0.110 to − 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (β = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (β = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (β = − 0.144; 95% CI: − 0.255 to − 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (β = − 0.018; 95% CI: − 0.026 to − 0.009; p < 0.001). No other significant level or trend changes were noted. Conclusions The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.

Ethical Dilemmas in Surgical Mission Trips During the COVID-19 Pandemic

This case is hypothetical and does not involve real patients or actual entities.

A long-running otolaryngology surgical teaching mission to Haiti was postponed in 2020 due to a combination of Haitian travel restrictions and American-based university travel bans during the coronavirus disease 2019 (COVID-19) pandemic. Several months have passed since the postponement of this recurring trip, and the local Haitian ear, nose, and throat (ENT) team has reached out to the international surgical teaching team to express their desire for surgical mission trips to return. The backlog of patients that the local team feels could not be treated without assistance continues to grow.

The COVID-19 vaccine is now available in the United States, and most US-based health care practitioners have been vaccinated, including all medical volunteers involved in this trip. University-based travel bans have also been lifted. Few Haitian health care providers have been vaccinated. Local Haitian travel restrictions are no longer being enforced, and it is legally possible to travel to the island. The international team has obtained enough personal protective equipment (PPE) to run a self-sufficient trip, but local PPE resources remain scarce.

Should the international surgical team restart mission work at this time? If so, what criteria need to be met for humanitarian organizations to provide safe and ethical care in the COVID-19 era when global inequality remains regarding vaccine distribution?

Neurosurgery in the Dutch Antilles: A Minireview of Recent Developments

Curaçao is an island in the Southern Caribbean Sea, which formed part of the Dutch Antilles and Aruba, Bonaire, part of Saint Martin, Saba, and Statia. Aruba was the first country of the Dutch Antilles to dissolute in 1986 . On October 10th of 2010, Curaçao and Saint Martin also became constituent countries within the Dutch kingdom. Bonaire, Saba, and Statia became “special municipalities,” also known as administrative divisions, within the Dutch state .

Curaçao is the biggest of the six islands, with an area of 444 km2/ 171.4 sq.mi, situated 65 km (40mi) north of the Venezuelan coast . Curaçao is of multi-cultural composition (mainly Afro-Caribbean) and has three official languages; Papiamentu, Dutch, and English. Spanish is widely spoken on the island as well.3 It has a little less the 160,000 inhabitants .

Genitourinary reconstructive surgery curriculum and postgraduate training program development in the Caribbean

Objectives: To describe the development of a genitourinary reconstructive fellowship curriculum and the establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the Caribbean.

Methods: In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We sought accreditation via a well-established local university, and fellowship candidates were selected. A database was maintained to track outcomes. Subjective and objective reviews were performed of the fellows.

Results: The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum was created and implemented. The fellowship has been successfully integrated into the health system, and the fellows performed 199 and 235 cases, respectively, during the program, completing all rotations successfully. They have been appointed to the national health system. Both graduates are now docents in the program and in the public system. Additional staff including radiologists, radiology technicians, nurses, urology residents (both Dominican and American), urology attendings, operating room staff, and anesthesia residents were trained as a result of the program.

Conclusions: To our knowledge, this is the first fellowship of its kind in the Caribbean. A novel curriculum was created and implemented, and the first 2 fellows have successfully completed all rotations. This training model may be transferable to additional sites.

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.

Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: the Critical Care General Anesthesia Syllabus (CC GAS)

Background
Despite an often severe lack of surgeons and surgical equipment, the rate-limiting step in surgical care for the nearly five billion people living in resource-limited areas is frequently the absence of safe anesthesia. During disaster relief and surgical missions, critical care physicians (CCPs), who are already competent in complex airway and ventilator management, can help address the need for skilled anesthetists in these settings.

Methods
We provided a descriptive analysis that CCPs were trained to provide safe general anesthesia, monitored anesthesia care (MAC), and spinal anesthesia using a specifically designed and simple syllabus.

Results
Six CCPs provided anesthesia under the supervision of a board-certified anesthesiologist for 58 (32%) cases of a total of 183 surgical cases performed by a surgical mission team at St. Luc Hospital in Port-au-Prince, Haiti in 2013, 2017, and 2018. There were no reported complications.

Conclusions
Given CCPs’ competencies in complex airway and ventilator management, a CCP, with minimal training from a simple syllabus, may be able to act as an anesthesiologist-extender and safely administer anesthesia in the austere environment, increasing the number of surgical cases that can be performed. Further studies are necessary to confirm our observation.

Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization for the Treatment of Infantile Hydrocephalus in Haiti

Objective: Untreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti.

Methods: The authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes.

Results: Of the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016-0.32, p < 0.001). Two children (2.4%) died of postoperative seizures.

Conclusions: As in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.