Kristin A. Sonderman

Hernia recurrence following inguinal hernia repair in children

PURPOSEnWe aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children.nnnMETHODSnWe used the TRICARE claims database, a national cohort of >3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children <12y who underwent IHR (2005-2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors.nnnRESULTSnNine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤1y in 37%, 2-3y in 23%, 4-5y in 16%, and 5-12y in 24%. Median follow-up time was 3.5y (IQR:1.6-6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209u202fdays [IQR:79-486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to >5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities.nnnCONCLUSIONSnThe incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤1y and those with multiple comorbidities were at increased risk.nnnLEVEL OF EVIDENCEnPrognosis Study, Level II.

Pathology and laboratory medicine in partnership with global surgery: working towards universal health coverage

www.thelancet.com Published online March 15,2018 http://dx.doi.org/10.1016/S0140-6736(18)30457-4 1 Pathology and laboratory medicine (PALM) is the backbone of high-quality care across many specialties, particularly surgery. In surgery, PALM provides the crossmatch to keep patients with bleeding ectopic pregnancies alive, the histopathology that differentiates a benign colonic polyp from a malignancy, the biochemistry that allows safe titration of anaesthetics, and the forensic pathology that quantifies the burden of disease. PALM and surgery, which both require substantial capital and infrastructure, share similarities as to the next phases of their expansion. Investment in equipment can only be cost-effective when the equipment is co-located with a well trained staff and a functioning supply chain to keep the equipment in use. All too often in lowincome and middle-income countries (LMICs), patients remain in need while analysers sit idly without reagents, or operating theatres are vacant without surgeons or equipment as coordination is lacking to simultaneously bring together these building blocks. Both specialties will benefit from delivery science research that addresses best practices for equipment standardisation, procurement, training, and service contracts, and the strengthening of biomedical engineering services. As the surgery community has found, getting from here to there will require PALM to coordinate the workforce, supplies, equipment, training, and the information and governance systems with national level planning. Strategic national planning in PALM and surgery must also include leveraging the fast pace of technology innovation. Technology in LMICs often undergoes so-called leapfrogging, in which new technologies are rapidly adopted without going through linear intermediary steps. In this Lancet Series on PALM in LMICs, Shahin Sayed and colleagues describe how point-of-care testing with HIV and malaria is likely to prove a leapfrog technology that could be adopted in areas where no testing previously existed without a traditional laboratory testing phase. Similarly, in Mongolia, open surgical techniques are being leapfrogged in favour of direct adoption of costeffective laparoscopic surgeries. PALM and the surgical, anaesthesia, and obstetrics communities encourage industry to recognise the large potential markets in LMICs and collaborate in research, development, trialling, and adopting new disruptive technologies. Workforce expansion in LMICs will also entail leapfrogging with the training of cost-effective task shifters, such as laboratory technicians, cancer histopathology technicians, nurse anaesthetists, and surgical officers. PALM and surgery seek resources not only for the community level but also for higher levels of care such as district and regional hospitals. Certain services within laboratory testing, pathology, and surgery are not needed at all levels of care, instead judicious deployment at specific levels of care and a functioning referral system are required. Working together, PALM and surgery and anaesthesia can shine a spotlight on the district hospital—a crucial but often neglected phase of the health-care system caught between a decentralisation agenda focused on the community and a super-specialisation agenda focused on national hospitals. The challenges that PALM and surgery face in advocating for resources are similar given their crosscutting nature and the breadth of diseases served, including cancer, heart disease, tuberculosis, trauma, and obstetrics. Both specialties are also excellent vehicles for health systems strengthening and can contribute to public health priorities, including the Sustainable Development Goals, non-communicable disease control, and universal health coverage. At the Pathology and laboratory medicine in partnership with global surgery: working towards universal health coverage

Testicular atrophy following inguinal hernia repair in children

PurposeWe sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.MethodsWe used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, includingu2009>u20093xa0million children. We abstracted data on male childrenu2009<u200912xa0years who underwent inguinal hernia repair (2005–2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.Results8897 children met inclusion criteria. Median age at hernia repair was 2xa0years (IQR 1–5). Median follow-up was 3.57xa0years (IQR 1.69–6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children

USAID: Current support for global surgery and implications of reform

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Forced Labor in Surgical and Healthcare Supply Chains

≤u20095xa0years, with 72% in children <u20092xa0years. Median time to atrophy was 2.4xa0years (IQR 0.64–3), with 30% occurring within 1xa0year and 75% within 3xa0years.ConclusionTesticular atrophy is a rare complication following inguinal hernia repair, with childrenu2009<u20092xa0years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.Level of evidencePrognosis Study, Level II.

Defining the National Burden of Pediatric Emergency General Surgery

BackgroundWorldwide, five billion people lack access to safe, affordable surgical, obstetric, and anaesthesia (SOA) care when needed. In many countries, a growing commitment to SOA care is culminating in the development of national surgical, obstetric, and anaesthesia plans (NSOAPs) that are fully embedded in the National Health Strategic Plan. This manuscript highlights the content and outputs from a World Health Organization (WHO) lead workshop that supported country-led plans for improving SOA care as a component of health system strengthening.MethodsIn March 2018, a group of 79 high-level global SOA stakeholders from 25 countries in the WHO AFRO and EMRO regions gathered in Dubai to provide technical and strategic guidance for the creation and expansion of NSOAPs.ResultsDrawing on the experience and expertise of represented countries that are at different stages of the NSOAP process, topics covered included (1) the global burden of surgical, obstetric, and anaesthetic conditions; (2) the key principles and components of NSOAP development; (3) the critical evaluation and feasibility of different models of NSOAP implementation; and (4) innovative financing mechanisms to fund NSOAPs.ConclusionsLessons learned include: (1) there is unmet need for the establishment of an NSOAP community in order to provide technical support, expertise, and mentorship at a regional level; (2) data should be used to inform future priorities, for monitoring and evaluation and to showcase advances in care following NSOAP implementation; and (3) SOA health system strengthening must be uniquely prioritized and not hidden within other health strategies.