Evaluation of a Ten-Year Team-Based Collaborative Capacity-Building Program for Pediatric Cardiac Surgery in Uzbekistan: Lessons and Implications

Background:
Most children who have congenital heart disease in low- and middle-income countries (LMICs), including Uzbekistan, do not receive adequate and timely pediatric cardiac surgical care. To strengthen the surgical capacity of a local pediatric cardiac surgery team in Tashkent, Uzbekistan, the JW LEE Center for Global Medicine at Seoul National University College of Medicine has developed a team-based training program and has been collaboratively conducting surgeries and care in order to transfer on-site knowledge and skills from 2009 to 2019.

Objectives:
To evaluate the long-term effects of the collaborative program on the cardiac surgical capacity of medical staff (teamwork, surgical complexity, and patients’ pre-surgical weights) as well as changes in the lives of the patients and their families. To derive lessons and challenges for other pediatric cardiac surgical programs in LMICs.

Methods:
To assess the effects of this ten-year long program, a mixed-methods design was developed to examine the trend of surgical complexity measured by Risk Adjustment for Congenital Heart Surgery 1 score (RACHS-1) and patients’ pre-surgical weights via medical record review (surgical cases: n = 107) during the decade. Qualitative data was analyzed from in-depth interviews (n = 31) with Uzbek and Korean medical staff (n = 10; n = 4) and caregivers (n = 17).

Findings:
During the decade, the average RACHS-1 of the cases increased from 1.9 in 2010 to 2.78 in 2019. The average weight of patients decreased by 2.8 kg from 13 kg to 10.2 kg during the decade. Qualitative findings show that the surgical capacity, as well as attitudes toward patients and colleagues of the Uzbek medical staff, improved through the effective collaboration between the Uzbek and Korean teams. Changes in the lives of patients and their families were also found following successful surgery.

Conclusions:
Team-based training of the workforce in Uzbekistan was effective in improving the surgical skills, teamwork, and attitudes of medical staff, in addition, a positive impact on the life of patients and their families was demonstrated. It can be an effective solution to facilitate improvements in pediatric cardiovascular disease in LMICs if training is sustained over a long period.

Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey

Background
Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods
A survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results
A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions
There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

Using modified Delphi method to propose and validate components of child injury surveillance system for Iran

Purpose
Child injuries are a public health concern globally. Injury Surveillance Systems (ISSs) have a beneficial impact on child injury prevention. There is a need for evidence-based consensus on frameworks to establish child ISSs. This research aims to investigate the key components of a child ISS for Iran and to propose a framework for implementation.

Methods
Data were gathered through interview with experts using unstructured questions from January 2017 to December 2018 to identify child ISS functional components. Qualitative data were analyzed using content analysis method. Then, modified Delphi method was used to validate the functional components. Based on the outcomes of the content analysis, a questionnaire with closed questions was developed to be presented to a group of experts. Consensus was achieved in two rounds.

Results
In round one, 117 items reached consensus. In round two, 5 items reached consensus and were incorporated into final framework. Consensus was reached for 122 items comprising the final framework and representing 7 key components: goals of the system, data sources, data set, coalition of stakeholders, data collection, data analysis and data distribution. Each component consisted of several sub-components and respective elements.

Conclusion
This agreed framework will assist in standardizing data collection, analysis and distribution to detect child injury problems and provide evidence for preventive measures.

Foreign body ingestion in children presenting to a tertiary paediatric centre in South Africa: A retrospective analysis focusing on battery ingestion

Background. Ingestion of foreign bodies remains a frequent reason for presentation to paediatric emergency departments worldwide. Among the variety of objects ingested, button batteries are particularly harmful owing to their electrochemical properties, which can cause extensive injuries if not diagnosed and treated rapidly. International trends show an increasing incidence of button battery ingestion, leading to concern that this pattern may be occurring in South Africa. Limited local data on paediatric foreign body ingestion have been published.

Objectives. To assess battery ingestion rates in a tertiary paediatric hospital. We hypothesised that the incidence has increased, in keeping with international trends. Secondary objectives included describing admission rates, requirements for anaesthesia and surgery, and promoting awareness of the problems associated with battery ingestion.

Methods. We performed a retrospective, descriptive analysis of the Red Cross War Memorial Children’s Hospital trauma database, including all children under 13 years of age seen between 1 January 2010 and 31 December 2015 with suspected ingestion of a foreign body. The ward admissions database was then examined to find additional cases in which children were admitted directly. After exclusion of duplicate records, cases were classified by type of foreign body, management, requirement for admission, anaesthesia and surgery. Descriptive statistics were used to analyse the data in comparison with previous studies published from this database.

Results. Patient age and gender patterns matched the literature, with a peak incidence in children under 2 years of age. Over the 6-year period, 180 patients presented with food foreign bodies, whereas 497 objects were classified as non-food. After exclusion of misdiagnosed cases, the remaining 462 objects were dominated by coins (44.2%). Batteries were the causative agent in 4.8% (22/462). Although the subtypes of batteries were not reliably recorded, button batteries accounted for at least 64% (14/22). Most children who ingested batteries presented early, but more required admission, anaesthesia and surgery than children who ingested other forms of foreign body.

Conclusions. The study demonstrated that the local incidence of button battery ingestion may be increasing, although data are still limited.Admission, anaesthesia and surgery rates for batteries were higher in this cohort than for all other foreign bodies. As button batteries can mimic coins, with much more dire consequences on ingestion, our ability to expedite diagnosis and management hinges on a high index of suspicion. It is imperative to increase awareness among healthcare workers and parents.

A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

Background: Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child’s ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child’s coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion.

Conclusion: A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

Impact of the coronavirus disease 2019 (COVID‐19) pandemic on pediatric oncology care in the Middle East, North Africa, and West Asia Region: A report from the Pediatric Oncology East and Mediterranean (POEM) Group

Background
Childhood cancer is a highly curable disease when timely diagnosis and appropriate therapy are provided. A negative impact of the coronavirus disease 2019 (COVID‐19) pandemic on access to care for children with cancer is likely but has not been evaluated.

METHODS
A 34‐item survey focusing on barriers to pediatric oncology management during the COVID‐19 pandemic was distributed to heads of pediatric oncology units within the Pediatric Oncology East and Mediterranean (POEM) collaborative group, from the Middle East, North Africa, and West Asia. Responses were collected on April 11 through 22, 2020. Corresponding rates of proven COVID‐19 cases and deaths were retrieved from the World Health Organization database.

Results
In total, 34 centers from 19 countries participated. Almost all centers applied guidelines to optimize resource utilization and safety, including delaying off‐treatment visits, rotating and reducing staff, and implementing social distancing, hand hygiene measures, and personal protective equipment use. Essential treatments, including chemotherapy, surgery, and radiation therapy, were delayed in 29% to 44% of centers, and 24% of centers restricted acceptance of new patients. Clinical care delivery was reported as negatively affected in 28% of centers. Greater than 70% of centers reported shortages in blood products, and 47% to 62% reported interruptions in surgery and radiation as well as medication shortages. However, bed availability was affected in <30% of centers, reflecting the low rates of COVID‐19 hospitalizations in the corresponding countries at the time of the survey.

Conclusions
Mechanisms to approach childhood cancer treatment delivery during crises need to be re‐evaluated, because treatment interruptions and delays are expected to affect patient outcomes in this otherwise largely curable disease.

Considerations for Newborn Screening for Critical Congenital Heart Disease in Low- and Middle-Income Countries

We propose several considerations for implementation of critical congenital heart disease (CCHD) screening for low- and middle-income countries to assess health system readiness for countries that may not have all the downstream capacity needed for treatment of CCHD. The recommendations include: (1) assessment of secondary and tertiary level CHD health services, (2) assessment of birth delivery center processes and staff training needs, (3) data collection on implementation and quality surgical outcomes, (4) budgetary consideration, and (5) consideration of the CCHD screening service as part of the overall patient care continuum.

Improving standard of pediatric surgical care in a low resource setting: the key role of academic partnership

Background: An epidemiological transition is interesting Sub-Saharan Africa increasing the burden of non-communicable diseases most of which are of surgical interest. Local resources are far from meeting needs and, considering that 50% of the population is less than 14 years of age, Pediatric surgical coverage is specially affected. Efforts are made to improve standards of care and to increase the number of Pediatric surgeons through short-term specialist surgical Missions, facilities supported by humanitarian organization, academic Partnership, training abroad of local surgeons. This study is a half term report about three-years Partnership between the University of Chieti- Pescara, Italy and the University of Gezira, Sudan to upgrade standard of care at the Gezira National Centre for Pediatric Surgery (GNCPS) of Wad Medani. Four surgical Teams per year visited GNCPS. The Program was financed by the Italian Agency for Development Cooperation.
Methods: The state of local infrastructure, current standard of care, analysis of caseload, surgical activity and results are reported. Methods utilized to assess local needs and to develop Partnership activities are described.
Results: Main surgical task of the visiting Team were advancements in Colorectal procedures, Epispadias/Exstrophy Complex management and Hypospadias surgery (20% of major surgical procedures at the GNCPS). Intensive care facilities and staff to assist more complex cases (i.e. neonates) are still defective. Proctoring, training on the job of junior surgeons, anaesthetists and nurses, collaboration in educational programs, advisorship in hospital management, clinical governance, maintenance of infrastructure together with training opportunities in Italy were included by the Program. Despite on-going efforts, actions have not yet been followed by the expected results. More investments are needed on Healthcare infrastructures to increase health workers motivation and prevent brain drain.
Conclusions: The key role that an Academic Partnership can play, acting through expatriated Teams working in the same constrained contest with the local workforce, must be emphasized. Besides clinical objectives, these types of Global Health Initiatives address improvement in management and clinical governance. The main obstacles to upgrade standard of care and level of surgery met by the Visiting Team are scarce investments on health infrastructure and a weak staff retention policy, reflecting in poor motivation and low performance.

Mitigating the impact of COVID-19 on children’s surgery in Africa

An outbreak of the disease known as COVID-19, which originated in Wuhan in the Hubei province of China, has rapidly spread to all continents of the globe. First detected via local hospital surveillance systems as a ‘pneumonia of unknown aetiology’ in late December 2019, the disease has since been declared a public health emergency of international concern by the WHO and reached pandemic status.

It is uncertain what the eventual toll of the pandemic will be in Africa; however, there has been a suspicion that the looming pandemic may hit harder than it has the rest of the world. Africa has baseline weaknesses in healthcare resource allocation, and her fragile healthcare systems are particularly vulnerable to being overwhelmed by this illness. Available statistics, to date, however, seem to show that the pandemic has been slow to begin. As of 26 May, 115 346 cases and 3471 deaths have been reported across the whole African continent, constituting 2% of all cases in the globe. African nations have had an opportunity to prepare for the coming onslaught, learn from the experience in other countries and choose interventions that are tailor-made for the unique socioeconomic context.

Full text continued on open access link