Shelly Choo

Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool

Objectives  To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana.

Quantifying Surgical and Anesthetic Availability at Primary Health Facilities in Mongolia

BackgroundSignificant barriers limit the safe and timely provision of surgical and anaesthetic care in low- and middle-income countries. Nearly one-half of Mongolia’s population resides in rural areas where the austere geography makes travel for adequate surgical care very difficult. Our goal was to characterize the availability of surgical and anaesthetic services, in terms of infrastructure capability, physical resources (supplies and equipment), and human resources for health at primary level health facilities in Mongolia.MethodsA situational analysis of the capacity to deliver emergency and essential surgical care (EESC) was performed in a nonrandom sample of 44 primary health facilities throughout Mongolia.ResultsSignificant shortfalls were noted in the capacity to deliver surgical and anesthetic services. Deficiencies in infrastructure and supplies were common, and there were no trained surgeons or anaesthesiologists at any of the health facilities sampled. Most procedures were performed by general doctors and paraprofessionals, and occasionally visiting surgeons from higher levels of the health system. While basic interventions such as suturing or abscess drainage were commonly performed, the availability of many essential interventions was absent at a significant number of facilities.ConclusionsThis situational analysis of the availability of essential surgical and anesthetic services identified significant deficiencies in infrastructure, supplies, and equipment, as well as a lack of human resources at the primary referral level facilities in Mongolia. Given the significant travel distances to secondary level facilities for the majority of the rural population, there is an urgent need to strengthen the delivery of essential surgical and anaesthetic services at the primary referral level (soum and intersoum). This will require a multidisciplinary, multi-sectoral effort aimed to improve infrastructure, procure and maintain essential equipment and supplies, and train appropriate health professionals.

Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews

BACKGROUND For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Biomechanical Properties of Skin in Massive Weight Loss Patients

BackgroundThe aim of this study is to assess skin strength in MWL patients relative to control cosmetic abdominoplasty patients biophysically, biochemically, and histologically. Growing success of weight loss programs has brought about an increase in the MWL population. Skin quality is thought to be impaired by MWL, but there are no compelling studies that have fully addressed the structural mechanisms involved.MethodsSkin from the medial and lateral abdomen was harvested fresh from patients undergoing cosmetic abdominoplasty (n = 6) or abdominal panniculectomy for MWL (n = 35), and burst strength was tested in the horizontal and vertical directions. Collagen content was measured, and histological studies were performed to assess epidermal and dermal thickness, vascularity as well as the morphology and density of the collagen fibers.ResultsIn all groups, skin stretched horizontally was stronger than skin stretched vertically (p < 0.001). The skin of MWL patients was stronger medially compared to the skin of cosmetic patients. (p = 0.047) Newly formed collagen was diminished in MWL than that in the control group, but the results were not statistically significant. Epidermal thickness was significantly higher medially in MWL (p = 0.049). Elastin fibers were decreased in the MWL group, while dermal vascularity was higher in the MWL group.ConclusionsThe skin of MWL patients demonstrated stronger mechanical parameters than that of cosmetic patients in the medial part of the abdomen; however, the decrease in elastic fibers associated with a decrease in newly formed collagen seemingly provides a contradiction. Skin changes with MWL merits further study to understand it more completely.

Surgical training and experience of medical officers in Ghana's district hospitals.

Purpose To document the quality of training and experience of those who care for patients undergoing surgery and emergency obstetrical procedures at 10 government district hospitals in Ghana. Method A study team composed of Ghanaian and U.S. surgeons visited 10 district hospitals in 10 different regions of Ghana in August 2009. On-site interviews were conducted documenting the formal and informal training and the experience of the medical officers (MOs) performing in surgical facilities in these hospitals. Results Fourteen of the 17 MOs working at these facilities were available for interviews. All 14 had completed two years of housemanship, which is similar to a rotating internship. Only one had obtained any formal surgical training beyond the housemanship, although all were responsible for performing major surgical procedures. The formal training under qualified supervision during the housemanship was limited; the mean number of the most common major surgical procedures performed during training ranged from four to eight, depending on the procedure. Conclusions Even though formal general surgical residency training in Ghana is well developed, graduates of these programs are not working in the district hospitals surveyed. The majority of surgical services provided at the district hospital are provided by MOs, who would benefit from more comprehensive training and ongoing supervision. To help meet the challenge of a shortage of physicians working at district hospitals, the authors present alternative approaches to care described in the literature that involve nonphysician midlevel health providers.

Benchmarking the quality of care of infants with low-risk gastroschisis using a novel risk stratification index

BACKGROUND The nationwide mortality of neonates with gastroschisis was compared to determine whether significant variations in outcome occurred at the hospital level. METHODS Utilizing a previously developed risk-stratification index, low-risk neonates with gastroschisis were identified by a score of < or = 2. Only hospitals that had a record of treating >25 low-risk neonates were included in the analysis. Hospital performance in treating infants with gastroschisis was categorized into moderate and extreme outliers. RESULTS A total of 4,344 neonates with gastroschisis were identified at 506 individual hospitals. Low-risk neonates had an overall mortality of 2.9% compared with high-risk neonates whose overall mortality was 24.4%. Forty hospitals treated >25 low-risk neonates in the years studied for a total of 1,775 low-risk patients. The mean, in-hospital mortality of this cohort was 3.1% (range, 0-14.3). Eight hospitals were moderate outliers with mortality rates between 3.8% and 8.0%. Two hospitals were extreme outliers with mortality rates of 8.6% and 14.3%. CONCLUSION A substantial variation exists in the mortality of neonates with low-risk gastroschisis across hospitals. Further improvements in survival may, thus, depend on targeting quality improvement initiatives to standardization of operative approaches as well improvements in nonoperative factors such as neonatal intensive care unit practices, nurse-to-patient ratios, and levels of intensivist staffing.

An Early Presenting Esophageal Schwannoma

Esophageal schwannoma is a rare diagnosis and historically has been a tumor of middle-aged females. We report a case of a 22-year-old male presenting initially with dyspnea secondary to tracheal compression from an 8 × 6 × 3.0 cm esophageal schwannoma. The tumor was surgically resected, and diagnosis was confirmed with immunohistochemical and pathological studies. We report the youngest case of esophageal schwannoma in an otherwise healthy individual.

Multidisciplinary management of focal nodular hyperplasia in children: experience with 10 cases.

Nonoperative management of focal nodular hyperplasia (FNH) is an accepted paradigm in adults, but current management strategies for children vary substantially between institutions. We reviewed medical records at Johns Hopkins Hospital between January 1, 1998, and December 31, 2008, to investigate the diagnosis, treatment, and outcome of pediatric patients with a pathologic diagnosis of FNH to provide additional data to help formulate management guidelines for this disease. Ten pediatric patients were identified as having a pathologic diagnosis of FNH, either by biopsy sample (n = 5) or hepatic resection (n = 5). The mean age of the patients was 12.1 years, and most were female (n = 7). Mean tumor size was 5.7 cm (range, 0.8-13 cm). Four of 5 patients whose FNH was diagnosed by biopsy alone developed no sequelae, and 1 patient eventually required surgery for mass effect. Patients with either large lesions (≥5 cm) or symptoms were referred for resection. Observational management of small lesions that can be confidently diagnosed as FNH appears to be safe and appropriate. Surgical resection should be reserved for large or symptomatic lesions amenable to resection.

Financial Analysis of Factors Impacting Reimbursement for Abdominoplasty

BackgroundWith growth in numbers of abdominoplasty procedures performed, we studied our experience with reimbursement and factors that impacted reimbursement and indirectly access to care.MethodsFrom July 2004 to June 2007, 245 patients had abdominoplasty. Demographic and financial variables were noted. Twenty different insurance plans were categorized as a single “commercial insurance” group in our analysis, and the other two study groups were “self-pay” and “Medicare” patients.ResultsOf the 245 patients studied, 87 paid for surgery (“self pay”), while 134 had commercial insurance, and 24 had Medicare. One hundred sixty patients (65%) had gastric bypass surgery (gbs). Medicare paid 28% less than insurance, and insurance paid 48% less than patients who prepaid. Of the 24 Medicare patients, 16 (67%) resulted in zero payment. On multiple logistic regression analysis, BMI, gbs history, and coincident hernia repair significantly impacted payment. BMI negatively impacted reimbursement, with every unit increase in BMI leading to a 0.77 percentage point reduction in reimbursement. Coincident hernia repair was associated with 17.5 percentage points reduction in reimbursement (p = 0.002). History of gbs improved reimbursement by a factor of 11 (p = 0.01). Neither age, gender, race, nor weight of tissue removed impacted reimbursement.ConclusionsHigher BMI and coincident hernia repair impaired reimbursement for abdominoplasty, while massive weight loss after gbs improved compensation. While having patients pay for their surgery guarantees the best reimbursement, strategies such as assuring authorization prior to surgery, which Medicare will not do, will secure better reimbursement.

Extracorporeal fetal support: a new animal model with preservation of the placenta.

BACKGROUND Previous models of support for premature sheep fetuses have consisted of cesarean delivery followed by catheterization of umbilical or central vessels and support with extracorporeal membrane oxygenation (ECMO). The limitations of these models have been insufficient blood flow, significant fetal edema, and hemorrhage related to anticoagulation. METHODS We performed a gravid hysterectomy on 13 ewes between 135 and 145days gestational age. The uterine vessels were cannulated bilaterally and circulatory support was provided via ECMO. Successful transition was defined as maintenance of fetal heart rate for 30minutes after establishing full extracorporeal support. Circuit flow was titrated to maintain mixed venous oxygen saturation (SvO2) of 70-75%. RESULTS Seven experiments were successfully transitioned to ECMO, with an average survival time of 2hours 9minutes. The longest recorded time from cannulation to death was 6hours 14minutes. By delivering a circuit flow of up to 2120ml/min, all but one of the transitioned uteri were maintained within the desired SvO2 range. CONCLUSION We report a novel animal model of fetal ECMO support that preserves the placenta, mitigates the effects of heparin, and allows for increased circuit flow compared to prior techniques. This approach may provide insight into a technique for future studies of fetal physiology.