Browsing by Author "Kushner, Adam L"

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Acute Care Surgery in Rwanda: Operative Epidemiology and Geographic Variations in Access to Care
(Mosby-Elsevier, 360 Park Avenue South, New York, Usa, Ny, 10010-1710, 2015) Wong, Evan G; Ntakiyiruta, Georges; Rousseau, Mathieu C; Ruhungande, Landouald; Kushner, Adam L; Liberman, Alexander S; Khwaja, Kosar; Dakermandji, Marc; Wilson, Marnie; Razek, Tarek; Kyamanywa, Patrick; Deckelbaum, Dan L
Background Surgical management of emergent, life-threatening diseases is an important public health priority. The objectives of this study were to (1) describe acute care general surgery procedures performed at the largest referral hospital in Rwanda and (2) understand the geographic distribution of disease presentations and referral patterns. Methods We performed a retrospective review of prospectively collected acute care surgery cases performed at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda between June 1 and December 1, 2011. Using Pearson's χ2 test and the Fisher exact test, we compared cases originating from within Kigali and transfers from other provinces. Geospatial analyses also were used to further describe transfer patterns. Results During the study period, 2,758 surgical interventions were performed, of which 25.6% (707/2,758) were general surgery operations. Of these, 45.4% (321/707) met the definition of acute care surgery. Only about one-third—32.3% (92/285)—of patients resided within Kigali, whereas about two-thirds—67.7% (193/285)—were transferred from other provinces. Most patients transferred from other provinces were younger than 18 years of age (40.4%; 78/193), and 83.0% (39/47) of patients older than 50 years of age originated from outside of Kigali. Specific operative indications and surgical procedures varied substantially between patients from Kigali and patients transferred from other provinces. Conclusion Emergency surgical conditions remain important contributors to the global burden of disease, particularly in low- and middle-income countries. Geographic variations exist in terms of operative diagnoses and procedures, which implies a need for improved access to surgical care at the district level with defined transfer mechanisms to greater-level care facilities when needed.
Estimating Operative Disease Prevalence in a Low-income Country: Results of a Nationwide Population Survey in Rwanda
(MOSBY-ELSEVIER , 360 PARK AVENUE SOUTH, NEW YORK, USA, NY, 10010-1710, 2013) Petroze, Robin T; Groen, Reinou S; Niyonkuru, Francine; Mallory, Melissa; Ntaganda, Edmond; Joharifard, Shahrzad; Guterbock, Thomas M; Kushner, Adam L; Kyamanywa, Patrick; Calland, J Forrest
Background. Operative disease is estimated to contribute to 11% of the global burden of disease, but no studies have correlated this figure to operative burden at the community level. We describe a survey tool that evaluates population-based prevalence of operative conditions and its first full-country implementation in Rwanda. Methods. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate an operative consultation or intervention. Household surveys in Rwanda were conducted in October 2011 in 52 clusters nationwide. Data were population-weighted and analyzed with the use of descriptive statistics. Results. A total of 1626 households (3175 individuals) were sampled with a 99% response rate. 41.2% (95% confidence interval [95 CI%] 38.8–43.6%) of the population has had at least one operative condition during their lifetime, 14.8% (95% CI 13.3–16.5%) had an operative condition during the previous 12 months, and 6.4% (95% CI 5.6–7.3%) of the population were determined to have a current operative condition. A total of 55.3% of the current operative need was found in female respondents and 40.3% in children younger than 15 years of age. A total of 32.9% of household deaths in the previous year may have been related to operative conditions, and 55.0% of responding households lacked funds for transport to the nearest hospital providing general practitioner operative services. Conclusion. The SOSAS survey tool provides important insight into the burden of operative disease in the community. Our results show a high need for operative care, which has important implications for the global operative community as well as for local health system strengthening in Rwanda. (Surgery 2012)
Injury Assessment in Three Low-resource Settings: A Reference for Worldwide Estimates
(Elsevier Science Inc , Ste 800, 230 Park Ave, New York, Usa, Ny, 10169, 2015) Gupta, Shailvi; Wren, Sherry M; Kamara, Thaim B; Shrestha, Sunil; Kyamanywa, Patrick; Wong, Evan G; Groen, Reinou S; Nwomeh, Benedict C; Kushner, Adam L; Price, Raymond R
Background Trauma has become a worldwide pandemic. Without dedicated public health interventions, fatal injuries will rise 40% and become the 4th leading cause of death by 2030, with the burden highest in low-income and middle-income countries (LMICs). The aim of this study was to estimate the prevalence of traumatic injuries and injury-related deaths in low-resource countries worldwide, using population-based data from the Surgeons OverSeas Assessment of Surgical Need (SOSAS), a validated survey tool. Methods Using data from three resource-poor countries (Nepal, Rwanda, and Sierra Leone), a weighted average of injury prevalence and deaths due to injury was calculated and extrapolated to low-resource countries worldwide. Injuries were defined as wounds from road traffic injuries (bus, car, truck, pedestrian, and bicycle), gunshot or stab or slash wounds, falls, work or home incidents, and burns. The Nepal study included a visual physical examination that confirmed the validity of the self-reported data. Population and annual health expenditure per capita data were obtained from the World Bank. Low-resource countries were defined as those with an annual per capita health expenditure of US$100 or less. Findings The overall prevalence of lifetime injury for these three countries was 18·03% (95% CI 18·02–18·04); 11·64% (95% CI 11·53–11·75) of deaths annually were due to injury. An estimated prevalence of lifetime injuries for the total population in 48 low-resource countries is 465·7 million people; about 2·6 million fatal injuries occur in these countries annually. Interpretation The limitations of this observational study with self-reported data include possible recall and desirability bias. About 466 million people at a community level (18%) sustain at least one injury during their lifetime and 2·6 million people die annually from trauma in the world's poorest countries. Trauma care capacity should be considered a global health priority; the importance of integrating a coordinated trauma system into any health system should not be underestimated.
Prevalence of Breast Masses and Barriers to Care: Results From a Population‐based Survey in Rwanda and Sierra Leone
(Wiley , 111 River St, Hoboken, Usa, Nj, 07030-5774, 2014) Ntirenganya, Faustin; Petroze, Robin T; Kamara, Thaim B; Groen, Reinou S; Kushner, Adam L; Kyamanywa, Patrick; Calland, J Forrest; Kingham, T Peter
Background and Objectives:Breast cancer incidence may be increasing in low‐and middle‐income countries (LMIC). This study estimates theprevalence of breast masses in Rwanda (RW) and Sierra Leone (SL) and identifies barriers to care for women with breast masses. only.Methods:Data were collected from households in RW and SL using Surgeons Overseas Assessment of Surgical Need (SOSAS), a cross‐sectional,randomized, cluster‐based population survey designed to identify surgical conditions. Data regarding breast masses and barriers to care in womenwith breast masses were analyzed.Results:3,469 households (1,626 RW; 1,843 SL) were surveyed and 6,820 persons (3,175 RW; 3,645 SL) interviewed. Breast mass prevalence was3.3% (SL) and 4.6% (RW). Overall, 93.8% of masses were in women, with 49.1% (SL) and 86.1% (RW) in women>30 years. 73.7% (SL) and92.4% (RW) of women reported no disability; this was their primary reason for not seeking medical attention. Overall, 36.8% of women who reportedmasses consulted traditional healers only.Conclusions:For women in RW and SL, minimal education, poverty, and reliance on traditional healers are barriers to medical care for breastmasses. Public health programs to increase awareness and decrease barriers are necessary to lower breast cancer mortality rates in low‐and middle‐income countries (LMIC).
Road Traffic Injuries: Cross-sectional Cluster Randomized Countrywide Population Data From 4 Low-income Countries
(Elsevier Science Inc , Ste 800, 230 Park Ave, New York, USA, NY, 10169, 2018) Zafar, Syed Nabeel; Canner, Joseph K; Nagarajan, Neeraja; Kushner, Adam L; Gupta, Shailvi; Tran, Tu M; Stewart, Barclay T; Kamara, Thaim B; Kyamanywa, Patrick; Amatya, Kapendra S; Galukande, Moses; Petroze, Robin T; Nwomeh, Benedict C; Smith, Emily R; Haglund, Michael M; Benedict Nwomeh, Benedict; Groen, Reinou S
Introduction Road traffic injuries (RTI) are a leading cause of morbidity and mortality around the world. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using nationally representative survey data. Methods The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, and disability from injury was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate. Results A total of 13,765 respondents from 7115 households in the four countries were surveyed. RTIs occurred in 2.2% (2.0–2.5%) of the population and accounted for 12.9% (11.5–14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years); 74% were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (requiring anesthesia). Major disability resulting in limitations of work or daily activity occurred in 38.5% (33.0–43.9%). Conclusion RTIs account for a significant proportion of disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, improved access to timely emergency, trauma and surgical care may help alleviate the burden due to RTI in LMICs.
Self-reported Determinants of Access to Surgical Care in 3 Developing Countries
(Amer Medical Assoc , 330 N Wabash Ave, Ste 39300, Chicago, Usa, Il, 60611-5885, 2016) Forrester, Joseph D; Forrester, Jared A; Kamara, Thaim B; Groen, Reinou S; Shrestha, Sunil; Gupta, Shailvi; Kyamanywa, Patrick; Petroze, Robin T; Kushner, Adam L; Wren, Sherry M
IMPORTANCE Surgical care is recognized as a growing component of global public health. OBJECTIVE To assess self-reported barriers to access of surgical care in Sierra Leone, Rwanda, and Nepal using the validated Surgeons OverSeas Assessment of Surgical Need tool. DESIGN, SETTING, AND PARTICIPANTS Data for this cross-sectional, cluster-based population survey were collected from households in Rwanda (October 2011), Sierra Leone (January 2012), and Nepal (May and June 2014) using the Surgeons OverSeas Assessment of Surgical Need tool. MAIN OUTCOMES AND MEASURES Basic demographic information, cost and mode of transportation to health care facilities, and barriers to access to surgical care of persons dying within the past year were analyzed. RESULTS A total of 4822 households were surveyed in Nepal, Rwanda, and Sierra Leone. Primary health care facilities were commonly reached rapidly by foot (>70%), transportation to secondary facilities differed by country, and public transportation was ubiquitously required for access to a tertiary care facility (46%-82% of respondents). Reasons for not seeking surgical care when needed included no money for health care (Sierra Leone: n = 103; 55%), a person dying before health care could be arranged (all countries: 32%-43%), no health care facility available (Nepal: n = 11; 42%), and a lack of trust in health care (Rwanda: n = 6; 26%). CONCLUSIONS AND RELEVANCE Self-reported determinants of access to surgical care vary widely among Sierra Leone, Rwanda, and Nepal, although commonalities exist. Understanding the epidemiology of barriers to surgical care is essential to effectively provide surgical service as a public health commodity in developing countries.
Surgical Care Needs of Low-resource Populations: An Estimate of the Prevalence of Surgically Treatable Conditions and Avoidable Deaths in 48 Countries
(Elsevier Science Inc , Ste 800, 230 Park Ave, New York, Usa, Ny, 10169, 2015) Gupta, Shailvi; Groen, Reinou S; Kyamanywa, Patrick; Ameh, Emmanuel A; Labib, Mohamed; Clarke, Damian L; Donkor, Peter; Derbew, Miliard; Sani, Rachid; Kamara, Thaim B; Shrestha, Sunil; Nwomeh, Benedict C; Wren, Sherry M; Price, Raymond R; Kushner, Adam L
Background Surgical care needs in low-resource countries are increasingly recognised as an important aspect of global health, yet data for the size of the problem are insufficient. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a population-based cluster survey previously used in Nepal, Rwanda, and Sierra Leone. Methods Using previously published SOSAS data from three resource-poor countries (Nepal, Rwanda, and Sierra Leone), a weighted average of overall prevalence of surgically treatable conditions was estimated and the number of deaths that could have been avoided by providing access to surgical care was calculated for the broader community of low-resource countries. Such conditions included, but were not limited to, injuries (road traffic incidents, falls, burns, and gunshot or stab wounds), masses (solid or soft, reducible), deformities (congenital or acquired), abdominal distention, and obstructed delivery. Population and health expenditure per capita data were obtained from the World Bank. Low-resource countries were defined as those with a per capita health expenditure of US$100 or less annually. The overall prevalence estimate from the previously published SOSAS data was extrapolated to each low-resource country. Using crude death rates for each country and the calculated proportion of avoidable deaths, a total number of deaths possibly averted in the previous year with access to appropriate surgical care was calculated. Findings The overall prevalence of surgically treatable conditions was 11·16% (95% CI 11·15–11·17) and 25·6% (95% CI 25·4–25·7) of deaths were potentially avoidable by providing access to surgical care. Using these percentages for the 48 low-resource countries, an estimated 288·2 million people are living with a surgically treatable condition and 5·6 million deaths could be averted annually by the provision of surgical care. In the Nepal SOSAS study, the observed agreement between self-reported verbal responses and visual physical examination findings was 94·6%. Such high correlation helps to validate the SOSAS tool. Interpretation Hundreds of millions of people with surgically treatable conditions live in low-resource countries, and about 25% of the mortality annually could be avoided with better access to surgical care. Strengthening surgical care must be considered when strengthening health systems and in setting future sustainable development goals.
Systematic Review of Surgical Literature From Resource-limited Countries: Developing Strategies for Success
(Springer , One New York Plaza, Suite 4600 , New York, United States, Ny, 10004, 2015) Pauyo, Thierry; Debas, Haile T; Kyamanywa, Patrick; Kushner, Adam L; Jani, Pankaj G; Lavy, Chris; Dakermandji, Marc; Ambrose, Hilary; Khwaja, Kosar; Razek, Tarek; Deckelbaum, Dan L
Background Injuries and surgical diseases are leading causes of global mortality. We sought to identify successful strategies to augment surgical capacity and research endeavors in low-income countries (LIC’s) based on existing peer-reviewed literature. Methods A systematic review of literature from or pertaining to LIC’s from January 2002 to December 2011 was performed. Variables analyzed included type of intervention performed, research methodology, and publication demographics such as surgical specialty, partnerships involved, authorship contribution, place and journal of publication. Findings A total of 2049 articles met the inclusion criteria between 2002 and 2011. The two most common study methodologies performed were case series (44 %) and case reports (18 %). A total of 43 % of publications were without outcome measures. Only 21 % of all publications were authored by a collaboration of authors from low-income countries and developed country nationals. The five most common countries represented were Nepal (429), United States (408), England (170), Bangladesh (158), and Kenya (134). Furthermore, of countries evaluated, Nepal and Bangladesh were the only two with a specific national journal. Interpretation Based on the results of this research, the following recommendations were made: (1) Describe, develop, and stimulate surgical research through national peer-reviewed journals, (2) Foster centers of excellence to promote robust research competencies, (3) Endorse partnerships across regions and institutions in the promotion of global surgery, and (4) Build on outcome-directed research.
Trauma Care and Referral Patterns in Rwanda: Implications for Trauma System Development
(Cma-Canadian Medical Assoc , 1867 Alta Vista Dr, Ottawa, Canada, Ontario, K1g 5w8, 2016) Ntakiyiruta, Georges; Wong, Evan G; Rousseau, Mathieu C; Ruhungande, Landouald; Kushner, Adam L; Liberman, Alexander S; Khwaja, Kosar; Dakermandji, Marc; Wilson, Marnie; Razek, Tarek; Kyamanywa, Patrick; Deckelbaum, Dan L
Background: Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. Methods: We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ2 and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. Results: Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). Conclusion: To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions.