Anthony Nnaemeka Eze

Introduction: Gastroschisis mortality is disproportionately high in Africa due in part to delayed presentation and limited surgical capacity. Skilled birth attendants (SBAs) are often the first to encounter these babies and can be an important part of their stabilisation. We assessed baseline Ugandan SBA knowledge of gastroschisis and interest in a training course. Methods: Southwestern Ugandan SBAs were surveyed regarding practice patterns, common beliefs and training course interest. Data were analysed with descriptive statistics. Results: We recruited 121 participants (70 midwives, 51 nurses). Most had a certificate or diploma (n=117, 97%) and 85% had more than 3 years of experience (n=103). Eighty-seven (72%) SBAs had cared for babies with gastroschisis. Most reported that communities stigmatised families (n=67, 55%), saw the child as cursed (n=74, 61%), blamed the mother (n=69, 57%) and advised parents to kill (n=30, 24%) or abandon the child (n=55, 45%). Barriers to families seeking care included healthcare mistrust (n=3, 2%), hopelessness (n=37, 31%), lack of knowledge (n=51, 42%), transportation difficulties (n=54, 45%) and fear of impoverishment (n=84, 69%). Most SBAs were unsure of the cause of gastroschisis and only 6% (n=8) recognised fetal vascular interruption as the cause. While 57% (n=69) prioritised intestinal coverage, only 7% (n=9) and 5% (n=6) would place a nasogastric tube or fast the baby. Three midwives encouraged immediate breastfeeding. Antibiotics (n=22, 18%) and fluid resuscitation (n=19, 16%) were sometimes recommended. Most participants (n=119, 98%) desired a course on gastroschisis management, but 41% (n=50) reported time constraints as a barrier. Conclusions: Southwestern Ugandan SBAs encounter gastroschisis babies, have limited training in its management and desire a training course. Engaging SBAs into a task-sharing role on delivery is a promising next step. Additional studies will be needed to determine if this can improve gastroschisis survival by reducing delays in care and improving community awareness.

Background: Hemodialysis Reliable Outflow (HeRO) graft is vital for complex hemodialysis patients who have exhausted all other access options. Hemodialysis access-induced distal ischemia (HAIDI) is a serious complication, however, risk factors for HAIDI after HeRO graft operation are unknown. Methods: Institutional records were retrospectively reviewed for all index HeRO graft implantations performed between 2014 and 2023. Re-do HeRO grafts were excluded. Patient demographics, operative details, and postoperative outcomes were collected. Primary outcome was symptomatic HAIDI following HeRO surgery. Statistical analysis was performed using univariate tests, logistic regression analysis, and Kaplan-Meier estimates for patency. Results: Over the 10-year study period, 232 index HeRO surgeries were performed of which 23 (9.9%) developed symptomatic HAIDI. Patients with HAIDI were older than their counterparts (64.0 ± 13.7 vs 57.0 ± 13.3 y, p = 0.008). All other demographic factors and comorbidities were similar between groups ( p = NS each). For inflow, patients with HAIDI more frequently underwent brachial artery anastomosis (78.3% vs 65.1%, p = 0.04), and less frequently utilized a prior arteriovenous graft or fistula (8.7% vs 25.8%, p = 0.04). The use of a tapered graft was similar between groups (47.8% vs 31.1%, p = 0.10). On multivariable analysis, only patient age (hazard ratio (HR) 1.06 per year, 95% confidence interval [CI], 1.02–1.10, p = 0.003) was independently associated with symptomatic HAIDI. Tapered graft utilization was not associated with reduced risk of HAIDI (HR 0.75, 95% CI, 0.23–2.38, p = 0.61). Patients with HAIDI had significantly higher 30-day hospital readmission rates (34.8% vs 17.7%, p = 0.0049) and reduced secondary graft patency rates (1-year, 46.0 ± 11.4% vs 71.3 ± 3.6%; 3-year, 23.7 ± 11.1% vs 44.0 ± 4.8%, p = 0.01). Conclusion: Symptomatic HAIDI is fairly common after HeRO graft implantation and portends inferior long-term outcomes with older age being the only associated risk factor. Tapered conduits were not associated with reduced risk of HAIDI. These data are valuable for informed consent and shared decision-making among patients undergoing HeRO graft surgery.

Background: Pediatric colorectal conditions cause significant morbidity and financial strain in low‐ and middle‐income countries, but little is known regarding catastrophic health expenditure (CHE) for pediatric surgical management in sub‐Saharan Africa. We examined the familial financial impact of travel expenses for pediatric colorectal disease in Uganda. Method: Patients with ostomies who are awaiting elective surgery in southwestern Uganda were enrolled. Caregivers completed surveys on income, assets, and travel expenses. Group comparisons were analyzed. Results: One‐hundred ten patients consisting of 78 males (71%) and 32 females (29%) were enrolled. Most had anorectal malformations ( n = 59, 54%) followed by Hirschsprung's disease ( n = 22, 20%) and were otherwise healthy ( n = 96, 87%). Caregivers were mostly young mothers ( n = 86, 78%) of median age 29 years, who worked as farmers ( n = 69, 63%), and 65% ( n = 72) had less than a secondary education. Median monthly household income was 300,000 UGX ($78). Families took a median of four trips to the hospital, traveled a median one‐way distance of 200 km, and spent a median of 79,000 UGX ($20) on transportation. Based on transportation costs alone, 28% ( n = 30) of households experienced CHE. All families were uninsured; most relied on savings ( n = 79, 72%) or financial support from nongovernmental organizations ( n = 31, 28%). Risk of CHE increased as monthly income decreased ( p < 0.001). Lower income households (< 150K UGX; < 38) were at particular risk of CHE, with 73% ( n = 14) spending more than 10% of their income on transportation expenses. Conclusion: At least 28% of colorectal patients in our study experienced CHE from transportation costs alone. Much of this transportation was repeated trips to the hospital in unsuccessful attempts to obtain surgical care. Accounting for other out‐of‐pocket expenses and additional surgeries not included outside of the study period, it is likely that the rate of CHE is higher. In the future, a care coordination program to minimize wasted travel may reduce CHE.