A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education

Background
In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.

Objectives
We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.

Program design and implementation
In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.

Main achievements
In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program’s success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors.

Policy implications
The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Barriers to Trauma Care in South and Central America: a systematic review

Introduction
Trauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region.

Methods
OVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item bank.

Results
57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57).

Conclusion
Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries.

Practical considerations for expediting breast cancer treatment in Brazil

Patients in Brazil continue to present with late-stage breast cancer. Notwithstanding these figures, policies and programs to overcome this long-lasting scenario have had limited results. We enlist the main barriers for advancing breast cancer diagnosis in Brazil, based on the available evidence, and we propose feasible strategies that may serve as a platform to address this major public health challenge.

Neurotrauma Registry Implementation in Colombia: A Qualitative Assessment

Objectives Latin America is among several regions of the world that lacks robust data on injuries due to neurotrauma. This research project sought to investigate a multi-institution brain injury registry in Colombia, South America, by conducting a qualitative study to identify factors affecting the creation and implementation of a multi-institution TBI registry in Colombia before the establishment of the current registry.

Methods Key informant interviews and participant observation identified barriers and facilitators to the creation of a TBI registry at three health care institutions in this upper-middle-income country in South America.

Results The study identified barriers to implementation involving incomplete clinical data, limited resources, lack of information and technology (IT) support, time constraints, and difficulties with ethical approval. These barriers mirrored similar results from other studies of registry implementation in low- and middle-income countries (LMICs). Ease of use and integration of data collection into the clinical workflow, local support for the registry, personal motivation, and the potential future uses of the registry to improve care and guide research were identified as facilitators to implementation. Stakeholders identified local champions and support from the administration at each institution as essential to the success of the project.

Conclusion Barriers for implementation of a neurotrauma registry in Colombia include incomplete clinical data, limited resources and lack of IT support. Some factors for improving the implementation process include local support, personal motivation and potential uses of the registry data to improve care locally. Information from this study may help to guide future efforts to establish neurotrauma registries in Latin America and in LMICs.

Cerebral aneurysms in Africa: A scoping review

Introduction
The epidemiology, management, and prognosis of cerebral aneurysms in Africa remain poorly understood. Most data to date has been from modeling studies. The authors aimed to describe the landscape of cerebral aneurysms in Africa based on published literature.

Methods
Articles on cerebral aneurysms in Africa from inception to June 9, 2020, were pulled from multiple databases (Medline, World Health Organization (WHO) Global Health Library/Global Index Medicus African Journals Online, and Google Scholar). The search results were merged, uploaded into Rayyan. After deduplication, titles and abstracts were screened independently by four reviewers (FDT, USK, IN, NDAB) based on the pre-defined inclusion and exclusion criteria. A full-text review was conducted, followed by data extraction of study, patient, neuroimaging, therapeutic, and prognostic characteristics.

Results
Thirty-three articles were included in the full-text retrieval. These studies were published across 13 (24.0%) countries, notably in Morocco (30.3%, n = 10) and South Africa (15.2%, n = 5), and 14 (42.4%) of them were published on or after 2015. Together, the studies totaled 2289 patients; there was a female predominance in 18 (54.5%) study cohorts, and the most frequently cited aneurysms were located in the internal carotid (12.1%, n = 352) and anterior cerebral arteries (9.5%, n = 275). Open surgery (27.3%, n = 792) was the most widely used option in these studies ahead of coiling (3.2%, n = 94). The reported mortality rate following surgical intervention was 7.9%.

Conclusion
There are few peer-reviewed reports of aneurysm practice and variability in access to cerebral aneurysm care in Africa.

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

Background:
In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

Objective:
This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

Methods:
A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

Results:
The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

Conclusions:
This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic

Impact of the COVID-19 Pandemic on Oncology Clinical Research in Latin America (LACOG 0420)

PURPOSE
COVID-19 has affected cancer care worldwide. Clinical trials are an important alternative for the treatment of oncologic patients, especially in Latin America, where trials can be the only opportunity for some of them to access novel and, sometimes, standard treatments.

METHODS
This was a cross-sectional study, in which a 22-question survey regarding the impact of the COVID-19 pandemic on oncology clinical trials was sent to 350 representatives of research programs in selected Latin American institutions, members of the Latin American Cooperative Oncology Group.

RESULTS
There were 90 research centers participating in the survey, with 70 of them from Brazil. The majority were partly private or fully private (n = 77; 85.6%) and had confirmed COVID-19 cases at the institution (n = 57; 63.3%). Accruals were suspended at least for some studies in 80% (n = 72) of the responses, mostly because of sponsors’ decision. Clinical trials’ routine was affected by medical visits cancelation, reduction of patients’ attendance, reduction of other specialties’ availability, and/or alterations on follow-up processes. Formal COVID-19 mitigation policies were adopted in 96.7% of the centers, including remote monitoring and remote site initiation visits, telemedicine visits, reduction of research team workdays or home office, special consent procedures, shipment of oral drugs directly to patients’ home, and increase in outpatient diagnostic studies. Importantly, some of these changes were suggested to be part of future oncology clinical trials’ routine, particularly the ones regarding remote methods, such as telemedicine.

CONCLUSION
To our knowledge, this was the first survey to evaluate the impact of COVID-19 on Latin American oncology clinical trials. The results are consistent with surveys from other world regions. These findings may endorse improvements in clinical trials’ processes and management in the postpandemic period.

Recommendations for streamlining precision medicine in breast cancer care in Latin America.

Background
The incidence of breast cancer (BC) in LMICs has increased by more than 20% within the last decade. In areas such as Latin America (LA), addressing BC at national levels evoke discussions surrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine (PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for better patient outcomes. Thus, its application may aid in overcoming these barriers.
Recent findings
A panel of LA experts in fields related to BC and PM were provided with a series of relevant questions to address prior to a multi-day conference. Within this conference, each narrative was edited by the entire group, through numerous rounds of discussion until a consensus was achieved. The panel proposes specific, realistic recommendations for implementing CDx in BC in LA and other LMIC regions. In these recommendations, the authors strived to address all barriers to the widespread use and access mentioned previously within this manuscript.
Conclusion
This manuscript provides a review of the current state of CDx for BC in LA. Of most importance, the panel proposes practical and actionable recommendations for the implementation of CDx throughout the Region in order to identify the right patient at the right time for the right treatment.

Feasibility of the application of multimedia animations as preoperative guides for urgent abdominal surgeries in public hospitals in Brazi

Introduction: Preoperative education helps patients feel less anxious and improve self-care while decreasing hospitalization time and demand for postoperative analgesia. Health literacy, culture and language play vital roles in patients’ understanding of health issues and may influence treatment outcomes. Obstacles are more evident in low and middle income countries (LMICs), where inadequate patient education levels are higher and hospital resources lower. Methodology: This is a prospective pilot study assessing the feasibility of online preoperative multimedia animations as guides for surgical patients in an LMIC. Patients admitted to a public hospital in Brazil for acute cholecystitis or appendicitis were included. Feasibility was represented by acceptability rate and ease of integration with department protocols. Results: Thirty-four patients were included in the study. Twenty-six patients concluded the intervention (feasibility rate of 76.5%). Demographic factors seemed to affect results, indicated by higher acceptability from those with lower education levels, from younger patients and from women. No issues were reported regarding integration to local protocols. Discussion: Few studies have evaluated use of multimedia resources for preoperative patients. No studies assessed the use of animations and none analyzed digital patient education resources in an LMIC. This study demonstrated that the use of animations for patient education in LMICs is feasible. A step-based protocol approach is proposed by this study to aid the implementation of patient education digital interventions. Conclusion: The implementation of this tool is feasible and presents patients with easier access to appropriate and engaging information, allowing better surgical preparation and recovery. It can be offered online, allowing it to be sustainable while creating the foundations for a modern patient education culture in LMICs