Nasser Kakembo

Outcomes and unmet need for neonatal surgery in a resource-limited environment: Estimates of global health disparities from Kampala, Uganda

PURPOSE Reported outcomes of neonatal surgery in low-income countries (LICs) are poor. We examined epidemiology, outcomes, and met and unmet need of neonatal surgical diseases in Uganda. METHODS Pediatric general surgical admissions and consults from January 1, 2012, to December 31, 2012, at a national referral center in Uganda were analyzed using a prospective database. Outcomes were compared with high-income countries (HICs), and met and unmet need was estimated using burden of disease metrics (disability-adjusted life years or DALYs). RESULTS 23% (167/724) of patients were neonates, and 68% of these survived. Median age of presentation was 5days, and 53% underwent surgery. 88% survived postoperatively, while 55% died without surgery (p<0.001). Gastroschisis carried the highest mortality (100%) and the greatest mortality disparity with HICs. An estimated 5072 DALYs were averted by neonatal surgery in Uganda (met need), with 140,154 potentially avertable (unmet need). Approximately 3.5% of the need for neonatal surgery is met by the health system. CONCLUSIONS More than two thirds of surgical neonates survived despite late presentation and lack of critical care. Epidemiology and outcomes differ greatly with HICs. A high burden of hidden mortality exists, and only a negligible fraction of the population need for neonatal surgery is met by health services.

Gastroschisis in Uganda: Opportunities for improved survival

PURPOSE Neonatal mortality from gastroschisis in sub-Saharan Africa is high, while in high-income countries, mortality is less than 5%. The purpose of this study was to describe the maternal and neonatal characteristics of gastroschisis in Uganda, estimate the mortality and elucidate opportunities for intervention. METHODS An ethics-approved, prospective cohort study was conducted over a one-year period. All babies presenting with gastroschisis in Mulago Hospital in Kampala, Uganda were enrolled and followed up to 30days. Univariate and descriptive statistical analyses were performed on demographic, maternal, perinatal, and clinical outcome data. RESULTS 42 babies with gastroschisis presented during the study period. Mortality was 98% (n=41). Maternal characteristics demonstrate a mean maternal age of 21.8 (±3.9) years, 40% (n=15) were primiparous, and fewer than 10% (n=4) of mothers reported a history of alcohol use, and all denied cigarette smoking and NSAID use. Despite 93% (n=39) of mothers receiving prenatal care and 24% (n=10) a prenatal ultrasound, correct prenatal diagnosis was 2% (n=1). Perinatal data show that 81% of deliveries occurred in a health facility. The majority of babies (58%) arrived at Mulago Hospital within 12h of birth, however 52% were breastfeeding, 53% did not have intravenous access and only 19% had adequate bowel protection in place. Four patients (9%) arrived with gangrenous bowel. One patient, the only survivor, had primary closure. Average time to death was 4.8days [range<1 to 14days]. CONCLUSION The mortality of gastroschisis in Uganda is alarmingly high. Improving prenatal diagnosis and postnatal care of babies in a tertiary center may improve outcome.

A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda

Abstract This study examines the cost‐effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age. Methods A simulation model using a decision tree template was developed to project the cost and disability‐adjusted life‐years saved by a pediatric OR in a low‐income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost‐effectiveness ratio of a pediatric OR. One‐way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach. Results A pediatric OR averted a total of 6,447 disability‐adjusted life‐years /year (95% uncertainty interval 6,288–6,606) and cost

Colonic polyposis in a 15 year-old boy: Challenges and lessons from a rural resource-poor area.

41,182/year (UI 40,539–41,825) in terms of OR installation. The pediatric operating room had an incremental cost‐effectiveness ratio of

From procedure to poverty: out-of-pocket and catastrophic expenditure for pediatric surgery in Uganda

6.39 per disability‐adjusted life‐year averted (95% uncertainty interval of 6.19‐6.59), or

Not gastroschisis or omphalocele or anything in between: a novel congenital abdominal wall defect

397.95 (95% uncertainty interval of 385.41‐410.67) per life saved based on the countrys average life expectancy in 2015. These values were well within the WHO guidelines of cost‐effectiveness threshold. The net economic benefit amounted to

Pediatric surgical camps as one model of global surgical partnership: A Way Forward

5,336,920 for a year of operation, or

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study

16,371 per patient. The model remained robust with one‐way and probabilistic sensitivity analyses. Conclusion The construction of a pediatric operating room in Uganda is a cost‐effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource‐limited settings of Sub‐Saharan Africa.

Cost of Saving a Child’s Life: A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda

Introduction Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges. Presentation of case This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon. Discussion In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access. Conclusion Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.

Ugandan Medical Student Career Choices Relate to Foreign Funding Priorities

BACKGROUND Financial protection from catastrophic health care expenditure (CHE) and patient out-of-pocket (OOP) spending are key indicators for sustainable surgical delivery. We aimed to calculate these metrics for a hospital stay requiring surgery in Ugandas pediatric population. METHODS A survey was administered to family members of postoperative patients in the pediatric surgical ward at Mulago Hospital. Cost categories included direct medical costs, direct nonmedical costs, indirect costs, plus money borrowed and items sold to pay for the hospital stay. CHE was defined as spending greater than 10% of annual household expenditure. Costs were reported in Ugandan shillings and US dollars. RESULTS One hundred and thirty-two patient families were surveyed between November 2016 and April 2017. Median direct costs were