Benedict C. Nwomeh

History and development of trauma registry: lessons from developed to developing countries

BackgroundA trauma registry is an integral component of modern comprehensive trauma care systems. Trauma registries have not been established in most developing countries, and where they exist are often rudimentary and incomplete. This review describes the role of trauma registries in the care of the injured, and discusses how lessons from developed countries can be applied toward their design and implementation in developing countries.MethodsA detailed review of English-language articles on trauma registry was performed using MEDLINE and CINAHL. In addition, relevant articles from non-indexed journals were identified with Google Scholar.ResultsThe history and development of trauma registries and their role in modern trauma care are discussed. Drawing from past and current experience, guidelines for the design and implementation of trauma registries are given, with emphasis on technical and logistic factors peculiar to developing countries.ConclusionImprovement in trauma care depends on the establishment of functioning trauma care systems, of which a trauma registry is a crucial component. Hospitals and governments in developing countries should be encouraged to establish trauma registries using proven cost-effective strategies.

Use of Twitter to document the 2013 Academic Surgical Congress.

BACKGROUNDnSocial media is a cornerstone of modern society and its use in health care has rapidly expanded in recent years. Live Tweeting of professional meetings is a growing way for participants to communicate with peers. The goal of this study was to analyze the initial experience with implementation of a Twitter Team at the 2013 Academic Surgical Congress (ASC).nnnMATERIALS AND METHODSnFour ASC attendees were designated as the Twitter Team for the 2013 meeting. Organizational leadership prominently promoted the unique meeting hashtag (#2013ASC). Twdocs and TweetReach were used to aggregate data 1xa0wk after the meeting.nnnRESULTSnA total of 58 independent users posted tweets with the #2013ASC hashtag during the week of the meeting. Total tweets numbered 434, with 288 original tweets. Of the 37 users who were identifiable individuals, 19 were in attendance at the ASC; 18 of the identifiable individuals were members of either the Association for Academic Surgery and/or the Society of University Surgeons. The ASC Twitter Team was responsible for 76% of all #2013ASC tweets. The three most common content areas for tweets were promotional (147), content related from presidential sessions (96), and social (75).nnnCONCLUSIONSnTwitter provides a meaningful social media format for sharing information during academic surgical meetings. The use of Twitter sharply expands the available audience for meeting proceedings and broadens the discussion venue for scholarly activity. Tweeting the meeting represents an important future direction for information dissemination in academic surgery.

Pediatric Negative Appendectomy Rate: Trend, Predictors And Differentials

BACKGROUNDnAppendectomy is one of the most commonly performed emergency operations in children. The diagnosis of appendicitis can be quite challenging, particularly in children. We set out to determine the accuracy of diagnosis of appendicitis by analyzing the trends in the negative appendectomy rate (NAR) using a national database.nnnMATERIALS AND METHODSnAnalysis of the Kids Inpatient Database (KID) was performed for the years 2000, 2003, and 2006 on children with appendectomy, excluding incidental appendectomies. Children (<18 y) without appendicitis but who underwent appendectomies were classified as negative appendectomies (NA), and those with appendicitis as positive appendectomies (PA). Comparisons were made between those with PA versus NA by demographic characteristics. The subset of patients with NA was then further analyzed.nnnRESULTSnAn estimated 250,783 appendectomies met the inclusion criteria. The NAR was 6.7%. Length of stay (LOS) was longer in NA versus PA (7 versus 3 d, P < 0.05). The NAR was increased in children under 5 y (21.1% versus 5.4% for among the 5-10 y versus 5.9% among the >10 y, P < 0.0001) and in females (9.3% versus 5.1%, P < 0.001). On multivariate analysis, increasing age was associated with lower odds of NA (OR = 0.92, P < 0.001). Females, rural hospitals, and Blacks were significantly more likely to experience NA.nnnCONCLUSIONSnYounger age, female gender, Black ethnicity and rural hospitals are independent predictors of NA. These factors can be incorporated into diagnostic algorithms to improve the accuracy of diagnosis of appendicitis in children.

Definitive Exclusion of Biliary Atresia in infants with cholestatic jaundice: the role of percutaneous cholecysto-cholangiography

Definitive exclusion of biliary atresia in the infant with cholestatic jaundice usually requires operative cholangiography. This approach suffers from the disadvantage that sick infants are subjected to a time-consuming and potentially negative surgical exploration. The purpose of this study was to determine if percutaneous cholecysto-cholangiography (PCC) prevents unnecessary laparotomy in infants whose cholestasis is caused by diseases other than biliary atresia. This study is a 10xa0year retrospective review of all infants with persistent direct hyperbilirubinemia and inconclusive biliary nuclear scans who underwent further evaluation for suspected biliary atresia. A gallbladder ultrasound (US) was obtained in all patients. When the gallbladder was visualized, further imaging by PCC was done under intravenous sedation; otherwise, the standard operative cholangiogram (OCG) was performed, with liver biopsy as indicated. The primary outcome was the diagnostic accuracy of PCC, especially with respect to preventing a laparotomy. There were 35 infants with suspected biliary atresia, with a mean age of 8xa0weeks (range 1–14xa0weeks). Nine infants whose gallbladder was visualized by ultrasound underwent PCC that definitively excluded biliary atresia. Of this group, the most frequent diagnosis (five patients) was total parenteral nutrition-associated cholestasis. The other 26 infants with absent or decompressed gallbladder had laparotomy and OCG, which identified biliary atresia in 16 patients (61%). Laparotomy was avoided in all 9 patients who underwent PCC, thus reducing the negative laparotomy rate by 47%. There were no complications associated with PCC. Several alternative techniques to operative cholangiogram have been described for the definitive exclusion of biliary atresia, but many of these have distinct drawbacks. Advances in interventional radiology techniques have permitted safe percutaneous contrast evaluation of the biliary tree. Identification of a normal gall bladder on sonogram is highly predictive of the absence of biliary atresia. Further confirmation can be accurately obtained by a combination of PCC and percutaneous liver biopsy.

Variability in Gastroschisis Management: A Survey of North American Pediatric Surgery Training Programs

BACKGROUNDnThe optimal surgical management of gastroschisis has yet to be determined. We sought to define the practice patterns in the management of gastroschisis, and to ascertain the degree of variability among and within pediatric surgical training programs.nnnMATERIALS AND METHODSnAn electronic survey was sent to all second-year residents in ACGME-accredited pediatric surgery programs in the United States and Canada. The questionnaire evaluated operative strategies, pain control, complications, and adherence to institutional protocols.nnnRESULTSnOf the 38 pediatric surgical training programs, 27 second-year residents (71%) completed the survey. An institutional protocol was utilized in only one program, and 70% reported treatment variability among faculty. Attempted primary closure was the treatment of choice in 76% of centers, and routine silo placement at 24%. The location for routine silo placement was in the neonatal intensive care unit (77%), operating room (22%), and delivery room (1%). General anesthesia was used for all primary closures, while silos were placed using intravenous sedation at 36% of centers. The most frequent silo-related complication was dislodgement, reported by 80%. Other preformed silo complications included the inability to achieve primary fascial closure (27%) and intestinal injury (27%). When entering clinical practice, 74% of trainees stated that they would first attempt primary closure, while 22% favored routine placement of a preformed silo.nnnCONCLUSIONSnProtocol-driven care of infants with gastroschisis is rare in pediatric surgery training centers, leading to great variability in care between institutions, as well as among faculty within single programs. Data-driven protocols may improve care of infants with gastroschisis.

The pediatric surgery workforce in low- and middle-income countries: problems and priorities

Most of the world is in a surgical workforce crisis. While a lack of human resources is only one component of the myriad issues affecting surgical care in resource-poor regions, it is arguably the most consequential. This article examines the current state of the pediatric surgical workforce in low- and middle-income countries (LMICs) and the reasons for the current shortfalls. We also note progress that has been made in capacity building and discuss priorities going forward. The existing literature on this subject has naturally focused on regions with the greatest workforce needs, particularly sub-Saharan Africa (SSA). However, wherever possible we have included workforce data and related literature from LMICs worldwide. The pediatric surgeon is of course critically dependent on multi-disciplinary teams. Surgeons in high-income countries (HICs) often take for granted the ready availability of excellent anesthesia providers, surgically trained nurses, radiologists, pathologists, and neonatologists among many others. While the need exists to examine all of these disciplines and their contribution to the delivery of surgical services for children in LMICs, for the purposes of this review, we will focus primarily on the role of the pediatric surgeon.

Burns in Nepal: A population based national assessment

BACKGROUNDnBurns are ranked in the top 15 leading causes of the burden of disease globally, with an estimated 265,000 deaths annually and a significant morbidity from non-fatal burns, the majority located in low and middle-income countries. Given that previous estimates are based on hospital data, the purpose of this study was to explore the prevalence of burns at a population level in Nepal, a low income South Asian country.nnnMETHODSnA cluster randomized, cross sectional countrywide survey was administered in Nepal using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) from May 25th to June 12th, 2014. Fifteen of the 75 districts of Nepal were randomly chosen proportional to population. In each district, three clusters, two rural and one urban, were randomly selected. The SOSAS survey has two portions: the first collects demographic data about the households access to healthcare and recent deaths in the household; the second is structured anatomically and designed around a representative spectrum of surgical conditions, including burns.nnnRESULTSnIn total, 1350 households were surveyed with 2695 individuals with a response rate of 97%. Fifty-five burns were present in 54 individuals (2.0%, 95% CI 1.5-2.6%), mean age 30.6. The largest proportion of burns was in the age group 25-54 (2.22%), with those aged 0-14 having the second largest proportion (2.08%). The upper extremity was the most common anatomic location affected with 36.4% of burns. Causes of burns included 60.4% due to hot liquid and/or hot objects, and 39.6% due to an open fire or explosion. Eleven individuals with a burn had an unmet surgical need (20%, 95% CI 10.43-32.97%). Barriers to care included facility/personnel not available (8), fear/no trust (1) and no money for healthcare (2).nnnCONCLUSIONnBurns in Nepal appear to be primarily a disease of adults due to scalds, rather than the previously held belief that burns occur mainly in children (0-14) and women and are due to open flames. This data suggest that the demographics and etiology of burns at a population level vary significantly from hospital level data. To tackle the burden of burns, interventions from all the public health domains including education, prevention, healthcare capacity and access to care, need to be addressed, particularly at a community level. Increased efforts in all spheres would likely lead to a significant reduction of burn-related death and disability.

A quantitative analysis of surgical capacity in Santa Cruz, Bolivia

OBJECTIVESnThis investigation aimed to document surgical capacity at public medical centers in a middle-income Latin American country using the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) survey tool.nnnMATERIALS AND METHODSnWe applied the PIPES tool at six urban and 25 rural facilities in Santa Cruz, Bolivia. Outcome measures included the availability of items in five domains (Personnel, Infrastructure, Procedures, Equipment, and Supplies) and the PIPES index. PIPES indices were calculated by summing scores from each domain, dividing by the total number of survey items, and multiplying by 10.nnnRESULTSnThirty-one of the 32 public facilities that provide surgical care in Santa Cruz were assessed. Santa Cruz had at least 7.8 surgeons and 2.8 anesthesiologists per 100,000 population. However, these providers were unequally distributed, such that nine rural sites had no anesthesiologist. Few rural facilities had blood banking (4/25), anesthesia machines (11/25), postoperative care (11/25), or intensive care units (1/25). PIPES indices ranged from 5.7-13.2, and were significantly higher in urban (median 12.6) than rural (median 7.8) areas (P < 0.01).nnnCONCLUSIONSnThis investigation is novel in its application of a Spanish-language version of the PIPES tool in a middle-income Latin American country. These data document substantially greater surgical capacity in Santa Cruz than has been reported for Sierra Leone or Rwanda, consistent with Bolivias development status. Unfortunately, surgeons are limited in rural areas by deficits in anesthesia and perioperative services. These results are currently being used to target local quality improvement initiatives.

Laparoscopic Appendectomy in Children with Complicated Appendicitis: Ethnic Disparity Amid Changing Trend

BACKGROUNDnLaparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial.nnnMETHODSnA 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes.nnnRESULTSnAn estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001).nnnCONCLUSIONSnLA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.

Emerging ethical issues in pediatric surgery

With the rapid pace of technological advancement and changing political, social, and legal attitudes, physicians face new ethical dilemmas. For pediatric surgeons, these emerging issues affect our relationship with, and the care we provide, to our patients and their families. In this review, we explore issues related to professionalism in pediatric surgery practice, the value of apology, and the risks associated with sleep deprivation. Furthermore, we discuss how the imperative of patient safety presents an opportunity for specialty-driven effort to define standards for the surgical care of children and a responsible process for introducing surgical innovations. Finally, we remind pediatric surgeons of their ethical and professional duty to support clinical research, and advocate the acceptance of community equipoise as sufficient basis for enrolling children in clinical trials.