Child maltreatment remains a major health threat globally that requires the understanding of socioeconomic and cultural contexts to craft effective interventions. However, little is known about research agendas globally and the development of knowledge-producing networks in this field of study. This study aims to explore the bibliometric overview on child maltreatment publications to understand their growth from 1916 to 2018. Data from the Web of Science Core Collection were collected in May 2018. Only research articles and reviews written in the English language were included, with no restrictions by publication date. We analyzed publication years, number of papers, journals, authors, keywords and countries, and presented the countries collaboration and co-occurrence keywords analysis. From 1916 to 2018, 47,090 papers (53.0% in 2010?2018) were published in 9442 journals. Child Abuse & Neglect (2576 papers; 5.5%); Children and Youth Services Review (1130 papers; 2.4%) and Pediatrics (793 papers, 1.7%) published the most papers. The most common research areas were Psychology (16,049 papers, 34.1%), Family Studies (8225 papers, 17.5%), and Social Work (7367 papers, 15.6%). Among 192 countries with research publications, the most prolific countries were the United States (26,367 papers), England (4676 papers), Canada (3282 papers) and Australia (2664 papers). We identified 17 authors who had more than 60 scientific items. The most cited papers (with at least 600 citations) were published in 29 journals, headed by the Journal of the American Medical Association (JAMA) (7 papers) and the Lancet (5 papers). This overview of global research in child maltreatment indicated an increasing trend in this topic, with the world’s leading centers located in the Western countries led by the United States. We called for interdisciplinary research approaches to evaluating and intervening on child maltreatment, with a focus on low-middle income countries (LMICs) settings and specific contexts.
Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care.
Background
Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.
Methods
A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r w) and linear regression models.
Results
A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5–62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8–111.0), compared to 9.4 (IQR 3.4–13.4) for the United States and 5.5 (IQR 4.4–10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = −63.2; 95% CI −119.6 to −6.9; P = 0.036).
Conclusions
The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.
Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis.
The Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country’s surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.We did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.We included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%-27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.Efforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.
Chronic osteomyelitis: a continuing orthopaedic challenge in developing countries.
Nine patients with chronic osteomyelitis, three with problems due to diagnosis, three with dilemmas regarding treatment and three with other complications are presented. It is suggested that although the diagnosis of osteomyelitis in most cases is straightforward, presentation might sometimes be similar to other conditions, which can lead to a dilemma in the diagnosis. Because of the formidable complications, which may be difficult to manage and the difficulty in guaranteeing permanent cure, the best approach is prevention by judicious treatment of acute haematogenous osteomyelitis and of open fractures.
The economic consequences of neurosurgical disease in low- and middle-income countries.
OBJECTIVE The objective of this study was to estimate the economic consequences of neurosurgical disease in low- and middle-income countries (LMICs). METHODS The authors estimated gross domestic product (GDP) losses and the broader welfare losses attributable to 5 neurosurgical disease categories in LMICs using two distinct economic models. The value of lost output (VLO) model projects annual GDP losses due to neurosurgical disease during 2015-2030, and is based on the WHO’s “Projecting the Economic Cost of Ill-health” tool. The value of lost economic welfare (VLW) model estimates total welfare losses, which is based on the value of a statistical life and includes nonmarket losses such as the inherent value placed on good health, resulting from neurosurgical disease in 2015 alone. RESULTS The VLO model estimates the selected neurosurgical diseases will result in $4.4 trillion (2013 US dollars, purchasing power parity) in GDP losses during 2015-2030 in the 90 included LMICs. Economic losses are projected to disproportionately affect low- and lower-middle-income countries, risking up to a 0.6% and 0.54% loss of GDP, respectively, in 2030. The VLW model evaluated 127 LMICs, and estimates that these countries experienced $3 trillion (2013 US dollars, purchasing power parity) in economic welfare losses in 2015. Regardless of the model used, the majority of the losses can be attributed to stroke and traumatic brain injury. CONCLUSIONS The economic impact of neurosurgical diseases in LMICs is significant. The magnitude of economic losses due to neurosurgical diseases in LMICs provides further motivation beyond already compelling humanitarian reasons for action.
A global country-level comparison of the financial burden of surgery.
Abstract
Background
Approximately 30 per cent of the global burden of disease is surgical, and nearly one‐quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country‐level estimates exist of the financial burden of surgical access.
Methods
Using publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data.
Results
Direct medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub‐Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well‐being (negative correlation) and the percentage of a country’s gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery.
Conclusion
Country‐specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale‐up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.
Barriers to Cleft Lip and Palate Repair Around the World.
Cleft lip and/or palate (CLP) is estimated to occur in 1 out of every 700 births, but for many people residing in low- and middle-income countries this deformity may be repaired late in life or not at all. This study aims to analyze worldwide provider-perceived barriers to the surgical repair of CLP in low- and middle-income countries.From 2011 to 2014, Smile Train distributed a multiple-choice, voluntary survey to healthcare providers to identify areas of need in CLP care worldwide. Data on provider-reported barriers to care were aggregated by year, country, and larger world regions.A total of 1997 surveys were completed by surgeons and healthcare providers (60.7% response rate). The most commonly reported barriers were “patient travel costs” (60.7%), “lack of patient awareness” (54.1%), and “lack of financial support” (52.8%). “Patient travel costs” was the most commonly reported barrier in sub-Saharan Africa, the Middle East and North Africa, and South and Southeast Asia. “Lack of financial support” was the most commonly reported barrier in the Americas, Eastern Europe, and East Asia.This is the largest intercontinental study on healthcare provider-identified barriers to care, representing the limitations experienced by healthcare professionals in providing corrective surgery for CLP around the world. Financial risk protection from hidden costs, such as patient travel costs, is essential. Community health workers and nurses are critical for communication and linking CLP care to the rest of the community. Recognition of these barriers can inform future policy decisions, targeted by region, for surgical systems delivering care for patients with CLP worldwide.
Global Surgery 2030: a roadmap for high income country actors.
The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world’s new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.