Application of the research electronic data capture (REDCap) system in a low- and middle income country– experiences, lessons, and challenges

The challenges of reliably collecting, storing, organizing, and analyzing research data are critical in low- and middle-income countries (LMICs), particularly in Sub-Saharan Africa where several healthcare and biomedical research organizations have limited data infrastructure. The Research Electronic Data Capture (REDCap) System has been widely used by many institutions and hospitals in the USA for data collection, entry, and management and could help solve this problem. This study reports on the experiences, challenges, and lessons learned from establishing and applying REDCap for a large US-Nigeria research partnership that includes two sites in Nigeria, (the College of Medicine of the University of Lagos (CMUL) and Jos University Teaching Hospital (JUTH)) and Northwestern University (NU) in Chicago, Illinois in the United States. The largest challenges to this implementation were significant technical obstacles: the lack of REDCap-trained personnel, transient electrical power supply, and slow/ intermittent internet connectivity. However, asynchronous communication and on-site hands-on collaboration between the Nigerian sites and NU led to the successful installation and configuration of REDCap to meet the needs of the Nigerian sites. An example of one lesson learned is the use of Virtual Private Network (VPN) as a solution to poor internet connectivity at one of the sites, and its adoption is underway at the other. Virtual Private Servers (VPS) or shared online hosting were also evaluated and offer alternative solutions. Installing and using REDCap in LMIC institutions for research data management is feasible; however, planning for trained personnel and addressing electrical and internet infrastructural requirements are essential to optimize its use. Building this fundamental research capacity within LMICs across Africa could substantially enhance the potential for more cross-institutional and cross-country collaboration in future research endeavors.

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.

Incidence patterns, care continuum and impact of treatment on survival among women with breast cancer in Ghana and the United States

Breast cancer is the most commonly diagnosed cancer among women worldwide. Of the five breast cancer subtypes, triple negative breast cancer (TNBC) is the most aggressive subtype. Black women in the US and Ghana are more likely to be diagnosed with TNBC, at young ages and advanced stages. Combining information from Ghana and the US, this project identified the breast cancer care continuum in Ghana, examined the breast cancer incidence patterns in Ghana and the US and assessed the optimal surgical treatment for TNBC. In the first manuscript, we examined how women in Ghana navigate the healthcare system and factors that influence their decisions and ability to seek and access breast cancer care. We interviewed thirty-one women diagnosed with breast cancer in Kumasi, Ghana. Based on the findings from the interviews, we presented a framework showing specific steps in the pathways and how women transition from one step to another. In the second manuscript, we assessed factors explaining the younger age at breast cancer diagnosis among Ghanaian women compared to women in the US. To achieve these aims we analyzed breast cancer data from the Kumasi Cancer Registry, the only population-based cancer registry in Ghana, and compared it to the US Surveillance, Epidemiology and End Results (SEER) data. Population age structure, screening and cohort effects explain the younger age at breast cancer diagnosis among women in Ghana In the third manuscript, we examined whether the poor prognosis of TNBC warrants a more aggressive surgical approach and whether there is value in expanded use of radiation therapy among women with TNBC who receive mastectomy. We found that breast conserving surgery followed by radiotherapy is an effective treatment for women with early-stage TNBC. Findings from this dissertation are timely due to the rapidly rising burden of breast cancer in sub-Saharan Africa and persistent disparities in the US.

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?

Going Global: Interest in Global Health Among US Otolaryngology Residents

Background: To meet the rising interest in surgical global health, some surgical residency programs offer global health experiences. The level of interest in these programs, however, and their role in residency recruitment and career planning has not been systematically evaluated.

Objective: (1) Define interest in global health among Otolaryngology residents in the USA. (2) Assess engagement of Otolaryngology residencies in global health training. (3) Determine barriers to global health training in residency.

Methods: A survey questionnaire was developed and sent to all Otolaryngology Residency Program Directors for distribution to all current Otolaryngology residents in the US.

Results: A total of 91 complete surveys were collected. A majority of respondents felt that global health was either “very important” or “extremely important” (67%). Two-thirds of respondents had prior global health experience (68%). While 56% of respondents would definitely participate in a global health elective and 78% would likely or definitely participate, only 37% of residency programs offered a global health experience. The availability of a global health elective significantly correlated with residency match choice in respondents with previous global health experience. The three most common barriers to participation were insufficient time, insufficient funding, and lack of program.

Conclusion: Participation in bilateral and equitable international electives is a unique experience of personal and professional growth. There is an interest in these opportunities during residency training among Otolaryngology residents that is not reflected in availability within training programs. This suggests the need for development of humanitarian outreach exposure through global health experiences during surgical residency training.

Opportunities For Improvement in The Administration of Neoadjuvant Chemotherapy For T4 Breast Cancer: A Comparison of The United States and Nigeria

BACKGROUND
Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS
Cross‐sectional retrospective analysis included all non‐metastatic T4 BCa patients treated from 2010‐2016 at Memorial Sloan Kettering Cancer Center (New York, U.S.) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS
308 patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. 56/93 (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt.

Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative vs. 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five‐year survival was significantly shorter in Nigeria vs. the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5‐year survival (67% vs. 72%) and 5‐year recurrence‐free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION
Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.

Role of North America and AANS in Global Neurosurgery

Approximately 28% of the global burden of disease is surgical (1). There is an estimated deficit of 90,909 neurosurgeons globally, who must care for an additional 14 million neurosurgical patients annually (2). In a study published by Alkire et al. on global access to surgical care, it was revealed that approximately two-thirds of the world’s population, comprising 4.8 billion people, do not have access to timely, affordable, or safe surgical care. The study also concluded that 99.3% of Lower-Income Countries (LICs) and 96.7% of Lower Middle-Income Countries (LMICs) populations do not have access to safe surgery (3).

Historically, global health policies focused on specific issues like access to healthcare and outcomes of infectious disease treatment and vaccinations. In January 2014, the Lancet Commission on Global Surgery (LCoGS), headed by healthcare leaders from 111 countries, gathered in Boston to research and propose strategies to improve surgery access globally. One of the committee’s goals was to bring surgeons from different socio-economic strata under one roof to facilitate collaboration and fruitful exchange of ideas. The committee also motivated the higher-income countries of North America to collaborate and shrink the existing hiatus in surgical access present in lower and middle-income countries (4). Since then, significant progress has been achieved in this regard under the leadership of North American academic institutes, neurosurgical societies, non-governmental organizations (NGOs), and even individual surgeons

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening

Background
The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.
Methods
This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.
Results
Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.
Discussion
Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review

Background: Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care. Methods: A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs. Results: Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15–400 in Canada, USD 4–609 in Western Europe, and USD 58–438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40–71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively. Conclusions: We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to car

The Withdrawal of the United States From the World Health Organization and Its Impact on Global Neurosurgery

To the Editor:

Right now, in any low to middle income country (LMIC), a child has developed postinfectious life-threatening hydrocephalus or a mother has suffered a brain bleed after a motor vehicle collision. Their lives could be saved by neurosurgical procedures such as shunting, third ventriculostomies, or burr holes. In the poor countries of the world, these conditions are incredibly common and result in significant morbidity and mortality while taking a tremendous toll on national economies. The Lancet Commission on Global Surgery clearly demonstrated the utility in ensuring access to life-saving surgical interventions such as these.1 However, the efforts to help vulnerable people lead full and productive lives are now at profound risk due to the unfortunate decision by the United States to withdraw funding from the World Health Organization (WHO).

On July 7, 2020, the United States announced its withdrawal of large financial support to WHO due to concerns surrounding the agency’s coronavirus response. Global efforts in infectious disease control, nutrition, and education will certainly be impacted by this decision, but so will global neurosurgery. Defunding WHO could have a profound impact on the gains made in capacity-building efforts and improving access to neurosurgical care.

Global neurosurgery is the public health and clinical care of neurosurgical patients with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.2 The Lancet Commission on Global Surgery incorporates all surgical disciplines, including global neurosurgery. The release of the Commission sounded the alarm on the investment of interdependent components of a surgical system such as anesthesia staff, nurses, operating rooms, critical care services, and biomedical engineers.3 With better capacity comes better neurosurgery and consequently improved treatment of the millions of patients every year with life-altering neurosurgical disease.

So where does WHO fit in? The United Nations (UN) has outlined its Sustainable Developmental Goals, which are to be reached by 2030. Global neurosurgery is related to targets #3 and #17—the promotion of healthy lives and global partnerships, respectively.4 WHO is the coordinating authority regarding health within the UN.

WHO is mandated to implement the health priorities set by its member states (MSs). In 2015, the members of WHO unanimously passed a resolution calling for “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage.” The United States was a cosponsor of this historic resolution. Today, with the help of WHO and its key partners, more than 40 LMICs are currently in various stages of implementing the mandates of this resolution. Subspecialists such as neurosurgeons are transforming the profession by integrating the principle of health equity with WHO’s support. For example, WHO has partnered with the World Federation of Neurosurgical Societies (WFNS), the largest professional society within neurosurgery, to better understand the global neurosurgical disease burden and workforce deficits. This partnership also permits better access to local stakeholders to continue important advocacy efforts. Individual LMICs, under the WFNS-WHO partnership, can effectively push the agenda of improved neurosurgical care that is nationally or regionally specific.

At the World Health Assembly meeting in 2018, it was clear that WHO was increasing collaboration and communication between neurosurgical systems around the world.5 As Rosseau describes, neurosurgeons convened with health ministries and other key players to commit to “…sharing training, equipment, and other resources with the rest of the global surgery community.” Neurosurgeons seated at the table with WHO was a significant step in the right direction.

Finally, it is well known that WHO is one of the most significant champions of Universal Health Coverage (UHC). Neurosurgical care is part of UHC and thus needs to be protected at all costs. In a country like Uganda, where the average person makes $2280 USD/yr and may spend up to $1220 USD for a neurosurgical procedure, the economic burden on patients can be devastating.6 WHO encourages governments to strategically partner with the public and private sectors to ensure that all health needs, including neurosurgical ones, are economically met with the best quality of medicine available.

The global neurosurgery movement, as part of the broader global surgery movement, would not have been possible without WHO. The key stakeholders respect and depend on WHO to set global priorities and support the MS implementation of their mandates. Yes, WHO can improve. But the United States will be far more effective in driving the improvement as an MS. The consequences of withdrawal of funding from WHO are devastating and will adversely affect millions of people around the world and, in particular, neurosurgical patients.