Lessons for Latin America from Mexico’s Experience With Patient Safety and Covid Response

Globally, more than 1 in 10 patients continue to be harmed due to safety lapses during their care.[1] Unsafe care results in over three million deaths each year. The health burden of harm is estimated at 64 million Disability-Adjusted Life Years (DALYs) per year similar to that of HIV/AIDS. Most of this burden is in low- and middle-income countries (LMICs). Recent estimates suggest that as many as 4 in 100 people die from unsafe care in the developing world [1]. The COVID-19 pandemic has clearly shown the risk of patient harm. The estimated proportion of hospital-acquired COVID-19 cases ranges from 12.5% to 44% [1]. As many as one third of these cases are reported to be among healthcare staff.
In Mexico, the Patient Safety journey started in 2002, with the National Crusade for Quality in Health Care,[2] the first Quality Policy in Latin America. The efforts to improve patient safety in Mexico can be divided into three distinct waves. A fourth wave has commenced with the pandemic. These lessons on patient safety are even more important now in the COVID era and can be applied in the region and elsewher

Improving Pediatric Neuro-Oncology Survival Disparities in the United States–Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico

PURPOSE
Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children’s Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP.

PATIENTS AND METHODS
We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017.

RESULTS
Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017. CONCLUSION The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

Background
Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

Methods
A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher’s exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

Findings
In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

Interpretation
Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.

Venoarterial extracorporeal membrane oxygenation in heart surgery post-operative pediatric patients: A retrospective study at Christus Muguerza Hospital, Monterrey, Mexico

Objectives:
Extracorporeal membrane oxygenation is a life support procedure developed to offer cardiorespiratory support when conventional therapies have failed. The purpose of this study is to describe the findings during the first years using venoarterial extracorporeal membrane oxygenation in pediatric patients after cardiovascular surgery at Christus Muguerza High Specialty Hospital in Monterrey, Mexico.

Methods:
This is a retrospective, observational, and descriptive study. The files of congenital heart surgery post-operative pediatric patients, who were treated with venoarterial extracorporeal membrane oxygenation from January 2013 to December 2015, were reviewed.

Results:
A total of 11 patients were reviewed, of which 7 (63.8%) were neonates and 4 (36.7%) were in pediatric age. The most common diagnoses were transposition of great vessels, pulmonary stenosis, and tetralogy of Fallot. Survival rate was 54.5% and average life span was 6.3 days; the main complications were sepsis (36.3%), acute renal failure (36.3%), and severe cerebral hemorrhage (9.1%). The main causes of death were multi-organ dysfunction syndrome (27.3%) and cerebral hemorrhage (18.2%).

Conclusion:
The mortality rates found are very similar to those found in a meta-analysis report published in 2013 and the main complication and causes of death are also very similar to the majority of extracorporeal membrane oxygenation reports for these kinds of patients. Although the results are encouraging, early sepsis detection, prevention of cerebral hemorrhage, and renal function monitoring must be improved.

Delays to diagnosis and barriers to care for breast cancer in Mexico and Peru: a cross sectional study

Background
Delays to breast cancer diagnosis and treatment initiation are associated with worsened outcomes. However, population-based screening is impractical in many low-income and middle-income countries (LMICs) because of resource constraints and a lack of capacity to effectively diagnose and treat screen-detected disease. Mexico and Peru have similar mortality-to-incidence ratios for breast cancer. Unlike Peru, Mexico has attempted to implement mammography screening, although it remains opportunistic with low (20%) national coverage rates. The aim of this study was to compare delays and describe barriers to care among breast cancer patients in Mexico and Peru.

Methods
This international cross-sectional study included breast cancer patients interviewed at four public cancer hospitals in Mexico City between 2009 and 2011, and a federally-funded regional cancer institute in Trujillo, Peru in 2015. A Breast Cancer Delays Questionnaire, developed and validated in Mexico and modified for Peru, was administered to breast cancer patients during routine hospital visits at each location. Patient-related, diagnostic, and treatment delays were quantified, and barriers to care identified.

Findings
We included data from 597 Mexican women and 113 Peruvian women. Age at diagnosis did not differ between countries (53 years [Mexico] vs 54 years [Peru], p=0·266). Most women in both countries had breast cancer detected by symptoms (84% [Mexico] vs 93% [Peru]; p<0·001), although more women in Mexico were diagnosed by mammography screening (12% vs 6%) and screening clinical breast examination (4% vs 1%). Of patients with available stage information, the majority of disease was AJCC stage II or III at diagnosis (76% [n=597, Mexico] vs 91% [93, Peru]; p=0·014). More women in Mexico were diagnosed at an early stage (AJCC stage 0 or I) (14% [Mexico] vs 4% [Peru]). Total delay (symptom discovery or screening to initiation of treatment) did not differ between the two countries (median 210 days [IQR 128–415; n=597] Mexico vs 201 days [82–442; n=74] Peru; [p=0·71]). Diagnostic delay (first medical consultation to diagnosis) was the greatest contributor to overall delay (113 days [59–250; n=597, Mexico] vs 174 days [40–396; n=95, Peru]; p=0·105). Approximately 60% of all patients had diagnostic delays greater than 3 months. Less than half (44%) of Mexican patients visited more than two health-care facilities before the cancer centre, compared with 71% of Peruvian patients (p<0·001). Patients in both countries reported that barriers to prompt arrival at the cancer centre were: not knowing where to go, lack of money, spread out appointments, and diagnostic errors.

Interpretation
Improved diagnostic and referral systems are necessary to reduce delays to breast cancer care in Mexico and Peru. Such improvements are prerequisites to the establishment of maximally effective mammography screening programmes in LMICs.

Changes in Electrical Activity of the Masseter Muscle and Masticatory Force After the Use of the Masseter Nerve as Donor in Facial Reanimation Surgery

Introduction
The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim.
Objective
To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force.
Materials and Methods
An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements.
Results
The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter-buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 ( p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 ( p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 ( p = 0.1) after the procedure
Conclusion
Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status.

Retrospective Analysis of Chilean and Mexican GI Stromal Tumor Registries: A Tale of Two Latin American Realities

Purpose: Like other malignancies, GI stromal tumors (GIST) are highly heterogeneous. This not only applies to histologic features and malignant potential, but also to geographic incidence rates. Several studies have reported GIST incidence and prevalence in Europe and North America. In contrast, GIST incidence rates in South America are largely unknown, and only a few studies have reported GIST prevalence in Latin America.

Patients and methods: Our study was part of a collaborative effort between Chile and Mexico, called Salud con Datos. We sought to determine GIST prevalence and patients’ clinical characteristics, including survival rates, through retrospective analysis.

Results: Overall, 624 patients were included in our study. Our results found significant differences between Mexican and Chilean registries, such as stage at diagnosis, primary tumor location, CD117-positive immunohistochemistry status, mitotic index, and tumor size. Overall survival (OS) times for Chilean and Mexican patients with GIST were 134 and 156 months, respectively. No statistically significant differences in OS were detected by sex, age, stage at diagnosis, or recurrence status in both cohorts. As expected, patients categorized as being at high risk of recurrence displayed a trend toward poorer progression-free survival in both registries.

Conclusion: To the best of our knowledge, this is the largest report from Latin America assessing the prevalence, clinical characteristics, postsurgery risk of recurrence, and outcomes of patients with GIST. Our data confirm surgery as the standard treatment of localized disease and confirm a poorer prognosis in patients with regional or distant disease. Finally, observed differences between registries could be a result of registration bias.

Astrocytic Tumors in Mexico: An Overview of Characteristics and Prognosis in an Open Reference Center for Low-Income Population.

Objective:
The authors aimed to analyze the current epidemiology of high- and low-grade gliomas, follow-up strategies, and prognosis in a national reference center of a developing country.

Materials and Methods:
Medical records of patients diagnosed with intracranial gliomas from January 2012 to January 2016 were reviewed. Data were classified by age, symptoms, Karnofsky functional scale (KFS), tumor location, extent of resection (EOR), histopathology, hospital stay, Glasgow outcome scale (GOS), adjuvant treatments, overall survival (OS), and mortality.

Results:
Astrocytomas accounted for 28.2% of the intracranial tumors and 53.5% were male. Headache was the most common symptom, while sensory disturbance was the least frequent. The right cerebral hemisphere was involved in 56.5% of cases and frontal lobe in 31.3%. Gross total resection (GTR) was achieved in 18.1% cases, 35.3% subtotal resection, and 46.4% biopsy. Regarding the astrocytomas, 43.3% were low grade and 56.4% high grade. Low-grade tumors had the highest frequency in the fourth decade of life, while Grade III and IV in the fifth and seventh decades of life, respectively. In high-grade lesions, there was a slight male predominance (~1.4:1). The initial KFS was regularly 80 for low-grade gliomas and 60 for high-grade. By 1-month postdischarge, the score decreased by 10 points. About half of the patients (47.5%) received adjuvant therapy after surgery. From the Glasgow Outcome Scale (GOS), the majority had a form of disability and 30-month OS was above 88% for Grade I-II and 0% for Grade III and IV.

Conclusions:
Astrocytic tumors were the most frequently noted intra-axial tumors. Age, histological grade, and EOR are important prognostic factors. These results are similar to other reports; however, increased variability was noted when treatment-related factors were considered. Additional studies are necessary to identify the factors related to these treatment results.

Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis.

To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I2=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).Of the many studies examining FSWs’ sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.CRD42016029185.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.

BACKGROUND:
The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

METHODS:
The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

RESULTS:
Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

CONCLUSION:
Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.