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6/12/2018 Global Neurosurgery: Building Neurosurgery, Training, and Research Michael M. Haglund MD, PhD, MACM, FAANS, FCS (ECSA) Distinguished Professor of Neurosurgery, Neurobiology, and Global Health Division Chief, Duke Global Neurosurgery and Neurology Program Director, Duke Neurosurgery Training Program Program Director Uganda East African Neurosurgery Training Program Chief External Examiner, Fellowship in Neurosurgery COSECSA Duke Division of Global Neurosurgery and Neurology Disclosures: Nuvasive for DGNN Grant Funding for East Africa, UCB Pharmaceuticals for Epilepsy Centers of Excellence World Population Worldmapper.org 1 6/12/2018 World Physicians US: 3,600 Neurosurgeons Africa: 565 Neurosurgeons African Regions Northern Eastern Southern Central Western Neurosurgery in Africa 2007 Countries in East Africa Total Population No. of Neurosurgeons Ration Neurosurgeons to population Neurosurgical Centers Neurosurgery Training Program(s) Northern Africa and South Africa: 486 of 563 NSUs Morocco 32 million 171 1:187,000 15 6 Uganda 30 million 5 1:6 million 2 0 East Africa 270 million 320 million 27 1:10 million 13 5 3,600 1:88,000 17 in NC 95 United States 2 6/12/2018 Duke Neurosurgery East Africa Project Problems: 2007 1) 2) 3) 4) Only 1 Neurosurgeon for 6 million people in Uganda No technology (one ventilator in 1,500 bed hospital) No operating room dedicated to Neurosurgery No Neurosurgery training program to train more neurosurgeons Solutions: 4-Ts 1) Technology: Duke Global Health PLUS (Placement of Life-giving Useable Surplus): Dr. Dzau, Dr. Merson, Jane Pleasants 2) Twinning: Teams of 23-55 medical professionals (1-2 trips/year) 3) Training: Neurosurgery Training Program in Uganda (FIENS) 4) Top Down Approach: All specialties and their patients benefit Duke Twinning: One on One Training 2007- 2017: 438 Volunteers on 16 trips 31,600 hours, $2.1 million in donated time 417 surgeries Duke Technology Transfer: – Total Ten Years: • • • • • • • • • • 2007: $1,275, 000/ 9 tons equipment/supplies & $90,000 donations 2008: $1,875,000/ 8 tons equipment/supplies & $150,000 donations 2009: $ 750,000 / 4 tons equipment/supplies & $140,000 donations 2010: $ 1,3750,000/ 7 tons equipment/supplies & $135,000 donations 2012 (2): $ 875,000/ 8 tons equipment/supplies & $175,000 donations 2013 (2): $ 850,000/ 10 tons equipment/supplies & $240,000 donations 2014 (2): $1,125,000,000/ 11 tons equipment/supplies & $200,000 donations 2015 (2): $1,005,000/13 tons equipment/supplies & $375,000 donations 2016 (2): $ 950,000/12 tons equipment/supplies & $500,000 donations 2017 (2): $ 1,050,000/11 tons equipment/supplies & $275,000 donations Total: 44,118,536,000 UGX and 11,880,000,000 UGX in donations Total: $12,255,000 and 93 tons of equipment & supplies, $3,300,000 donations to develop three Neurosurgery Hospitals – Benefactors: – – – – – – Duke University Health System: Former Chancellor Victor Dzau, Jane Pleasants, Chancellor Eugene Washington Duke University: President Richard Brodhead Duke Global Health Institute: Director Michael Merson Division of Neurosurgery: Dr. Allan Friedman, Dr. John Sampson Corporate Support: Nuvasive, Synthes Spine, Integra Neuroscience, Biomet, K2M 3 Cases (n) FY 09 FY 09 FY 09 FY 09 FY 08 FY 08 qt r4 qt r3 qt r2 qt r1 qt r4 qt r3 qt r2 FY 09 FY 09 FY 09 FY 09 FY 08 FY 08 FY 08 qt r4 qt r3 qt r2 qt r1 qt r4 qt r3 qt r2 qt r1 Initiation Duke NSU Program 30 FY 08 qt r4 qt r3 qt r2 qt r1 qt r4 qt r3 Cases (n) 40 FY 08 FY 07 FY 07 FY 07 FY 07 FY 06 qt r2 qt r1 50 qt r1 qt r4 qt r3 qt r2 qt r1 qt r4 FY 06 FY 06 FY 06 Elective OR + Duke NSU Camp NSU Elective OR FY 08 FY 07 FY 07 FY 07 FY 07 FY 06 qt r3 Cases (n) 60 qt r2 qt r1 60 FY 06 FY 06 FY 06 6/12/2018 Neurosurgical Cases per Qtr 70 20 10 0 Neurosurgical Cases per Qtr 70 Elective OR + Duke NSU Camp NSU Elective OR 50 40 30 20 10 0 55 50 45 40 35 30 25 20 15 10 5 0 4 10% 6m o 20% m o 30% FY 09 2n d 40% 6m o 50% FY 09 1s t6 60% Start of Duke Neurosurgery Program 70% FY 08 2n d 80% m o 6m o m o 90% FY 08 1s t6 FY 07 2n d m o 6m o FY 07 1s t6 FY 06 2n d FY 06 1s t6 % Utilization Start of Duke Neurosurgery Program Cases (n) 6/12/2018 55 50 45 40 35 30 25 20 15 10 5 0 Elective Neurosurgery OR Utilization Elective Neurosurgery OR Utilization 100% 0% 5 6/12/2018 70 Cases (n) 60 50 40 30 20 FY09 10 FY08 FY07 0 multiple case days 2 case days FY06 3 case days 4 case days 70 Cases (n) 60 50 40 30 20 FY09 10 FY08 FY07 0 multiple case days 2 case days FY06 3 case days 4 case days 70 Cases (n) 60 50 40 30 20 FY09 10 FY08 FY07 0 multiple case days 2 case days FY06 3 case days 4 case days 6 6/12/2018 2500 163,000 153,000 New Admits 143,000 Total Surgical Cases 2100 133,000 1900 123,000 113,000 103,000 93,000 83,000 1700 1500 Total Surgical Cases (n) 2300 Initiation of Duke Project Admissions (n) Total Admits 1300 73,000 1100 FY06 FY07 FY08 FY09 2500 163,000 153,000 New Admits 143,000 Total Surgical Cases 2100 133,000 1900 123,000 113,000 103,000 93,000 83,000 1700 1500 Total Surgical Cases (n) 2300 Initiation of Duke Project Admissions (n) Total Admits 1300 73,000 1100 FY06 FY07 FY08 FY09 2500 163,000 153,000 New Admits 143,000 Total Surgical Cases 2100 133,000 1900 123,000 113,000 103,000 93,000 83,000 1700 1500 Total Surgical Cases (n) 2300 Initiation of Duke Project Admissions (n) Total Admits 1300 73,000 1100 FY06 FY07 FY08 FY09 7 6/12/2018 Uganda Neurosurgery Training Program: Co-Directors: Dr. Michael Muhumuza and Professor Michael Haglund Duke Neurosurgery Curriculum and East African NSTP Curriculum Start first two Ugandan residents Aug 2009: Dr. Obiga and Dr. Muhindo, Second set of two residents started August 2012 MMed Neurosurgery at Makerere University, Fall 2018 Currently 5 more in program, 2 starting summer 2018, total 7 residents Uganda East African Neurosurgery Training Program: Twinning Uganda residents spend one month at Duke observing in year 4 COSECSA Duke Neurosurgery Residents spend one week to 1 month Uganda PGY-5/6 Before new Neurosurgery Theater: Neurosurgeons operate 2 days/wk Trauma cases build up on Ward 3A Elective cases best for resident training pushed off for clearing Ward 3A trauma Hope to build capacity and training by building new NSU Theater 8 6/12/2018 Mulago gets Shs540m brain theatre Dr. Michael Haglund shows Health Minister Christine Ondoa the new equipment at the theatre. January 14, 2013 9 6/12/2018 Operating Theater #4: Alex Muhindo, Professor Haglund Thursday Case #7 10 6/12/2018 Duke Global Neurosurgery.. ..training Ugandans in Uganda TRAINING: 7 Neurosurgeons in Uganda 2013 Trained 5 graduates, 7 more in training, Goal: 50 neurosurgeons by 2030 COSECSA/ MMed TRAINED NEUROSURGEONS V I S I O N 2023 2020 2025 2024 2026 2013 2022 2022 2013 2016 50 Neurosurgeons for 62 million 1 NSU for 1.24 million 2 0 3 0 COSECSATrained TRAINED 300 General Surgeons by NEUROSURGEONS 50 Neurosurgeons V I S I O N 2025 2025 2030 2025 2018 2023 2025 2025 2030 2030 2017 2020 2030 2025 2030 2030 2022 2025 2030 2030 2025 2021 2021 2030 2030 2024 2021 2030 2025 2030 2025 2030 2021 2021 2030 2023 2019 2022 2024 2021 2030 2023 2021 2030 2021 2024 2030 2024 2024 2022 2020 2011 2011 2030 2030 2023 2030 2030 2030 2021 2030 2020 2015 2016 2020 2 0 3 0 2030 2030 2021 350 NSU trauma surgeons for 62 million 1 NSU trauma for 171,000 people 11 6/12/2018 The New Vision for Global Neurosurgery June 28, 2014 Meeting with new Chair of Neurosurgery, John Sampson, MD, PhD, MHS, MBA 12 6/12/2018 Published/Accepted (October 2014 – December 2015): 15 manuscripts 1. High Road Utilizers Surveys Compared to Police Data for Road Traffic Crash Hotspot Localization in Rwanda and Sri Lanka. Staton C, De Silva V, Krebs E, Andrade L, Rulisa S, Mallawaarachchi B, Jin K, Vissoci J, Ostbye T. BMC Public Health acceptance 13Dec2015 2. Road Traffic Injury Prevention Initiatives: a systematic review and metasummary of effectiveness in low and middle income countries Staton CA, Vissoci JRN, Gong E, Toomey N, Wafula R, Abdelgadir J, Zhou Y, Liu C, Pei F, Zick B, Ratliff C, Rotich C, Jadue N, Andrade L, von Isenburg M, Hocker M.Plos One acceptance 18Nov 2015 (Output of Global Injuries Course) 3. Building Neurosurgical capacity in low and middle income countries Anthony Fuller, Tu Tran, Michael Muhumuza, Michael M. Haglund Published online: November 3, 2015, eNeurologicalSci. 4. Surgeons OverSeas Assessment of Surgical Need (SOSAS) Uganda: update for household survey. Fuller A, Butler E, Tran T, Makumbi F, Luboga S, Muhumuza C, Chipman J, Groen R, Gupta S, Kushner A, Galukande M, Haglund M. World Journal of Surgery 2015 Dec, 39(12):2900 5. A prospective registry evaluating the epidemiology and clinical care of Traumatic Brain Injury patients presenting to a Regional Referral Hospital in Moshi, Tanzania: challenges and the way forward. Staton, Msilanga, Kiwango, Vissoci, Lester, Hocker, Gerardo, Mvungi Int J Inj Contr Saf Promot. 2015 Aug 4:1-9. PMID: 26239625 6. Burden of Surgical Conditions in Uganda: Pilot Study of a Population-Based Survey in Wakiso District, Uganda. Butler E, Tran T, Fuller A, Makumbi F, Luboga S, Kisakye S, Haglund M, Chipman J, Galukande M. Surgery. 2015 Sep;158(3):764-72. doi: 10.1016/j.surg.2015.05.011. Epub 2015 Jun 16. PMID: 26088920 7. Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda.Tran TM, Fuller AT, Kiryabwire J, Mukasa J, Muhumuza M, Ssenyojo H, Haglund MM.World Neurosurg. 2015 Mar;83(3):269-77. doi: 10.1016/j.wneu.2014.12.028. Epub 2014 Dec 19. PMID: 25529531 8. Central nervous system tumor distribution at a tertiary referral center in Uganda. Hatef J, Adamson C, Obiga O, Taremwa B, Ssenyojo H, Muhumuza M, Haglund M, Schroeder K. World Neurosurg. 2014 Sep-Oct; 82(3-4):258-65. doi: 10.1016/j.wneu.2014.06.040. Epub 2014 Jun 19. PMID: 24953304 Accepted with revisions. 9. Quality of the Development of Traumatic Brain Injury Clinical Practice Guidelines: A Systematic Review Patel, Abraham, Reid, Tran, Toomey, Vissoci, Rodrigues, Viera, Gerardo, Euker, Mvungi, Staton Accepted with revisions to PLoS One 10. Qualitative Evaluation of Trauma Delays in Road Traffic Injury Patients in Maringa, Brazil. Patel A, Vissoci JRN, Hocker M, Molina E, Morales Gil N, Staton C Accepted with minor revisions to PloS One DGNN Google Docs on April 27, 2018, 48 manuscripts in 24 months 13 6/12/2018 Neurosurgical Camp Mbarara, Uganda 2016 Uganda Neurosurgery Residency Mbarara, Uganda April 2016 Thanking Julie and other faculty Put in grants for Bass, others, UCB-Belgium grant, Nuvasive Grant Duke University Bass Foundation Research Group Kampala, Uganda July 2016 14 6/13/2018 Spinal Surgery in Ghana: How We Create A Center of Excellence O. Boachie-Adjei, M.D. DSc. President and Founder FOCOS CEO, Medical Director and Surgeon in Chief FOCOS Hospital Past President Scoliosis Research Society Prof. Orthopedic Surgery Weill Medical College of Cornell University Chief Emeritus Scoliosis Service Hospital For Special Surgery, New York Author’s Disclosure Information Oheneba Boachie-Adjei, MD DePuy Spine, (a,b,e) a) Grants/Research K2M, (a,b,d) Support b) Consultant Weigao Co (b,c) c) Stock/Shareholder d) e) Speakers’ Bureau Other Financial Support Global Health and Orthopedics – Ranking of major causes of death and disability (% DALYs) • Cardiovascular and circulatory diseases 11.8% • All neoplasms 7.6% • Mental and behavioural disorders 7.4% • Musculoskeletal disorders 6.8% The fourth greatest impact on the health of the world population, considering both death and disability (DALYs) (Lancet 15 December 2012) 1 6/13/2018 FOCOS Orthopaedic Hospital MISSION: To provide optimum orthopaedic care and improve quality of life in Ghana and other countries VISSION: A Sustainable infrastructure for state of the art orthopaedic care and education. Challenges • • • • Human Resources Finances Infrastructure Complex Orthopedic and medical conditions • Sustainability Human Resource Challenge 2 6/13/2018 USA, Mexico, Argentina. Spain, Italy, Norway, Japan, Turkey, Australia ,India, Nigeria, Sierra Leone, New. Zealand, Kenya, Greece Funding Challenge • Ghana fares poorly among African and global averages for total Expenditure on health. • The average Ghanaian cannot afford major orthopedic surgical care and the NHIS doesn't cover such surgical services. Fee For service and sponsorship program via Fundraising (30% patients subsidized) 3 6/13/2018 Health Expenditure Indicators 2014 Health Expenditure Indicators Ghana Value No Indicator 1 Total Expenditure on health as % of gross domestic product ( 2014) Africa Average Global Average 5.5 10.0 47.8 60.1 52.2 39.9 10.0 15.5 60.1 45.5 107 1057 51 635 3.6 2 General government expenditure on health as % of total expenditure on health (2014) 3 Private expenditure on health as % of total expenditure on health (2014) General government expenditure on health as % of total government expenditure ( 2014) 4 5 Out-of-pocket expenditure on health as % of private expenditure on health(2014) 6 Per Capita total expenditure on health at average exchange rate (US$) (2014) 7 Per capita government expenditure on health at average exchange rate (US$) (2014) 59.8 40 7.0 67 58 35 FOCOS Funding strategies • • • • • • • • Government Seed Grant FOCOS-MOH CO-Consignment initiatives for imports International Volunteerism International Multi-industry partnership Global Private donors and Benefactors Private foundation sponsorships of patients FOCOS USA GRANTS Private Loans Global Partners 4 6/13/2018 STATE OF THE ART HOSPITAL FOCOS Surgical THEATRE • Twin operating theaters with state of the art equipment – Advanced anaesthesia machines, cell savers, neuro-monitoring devices, Carms, high definition cameras. • Headed by a qualified perioperative nurse manager INTENSIVE CARE UNIT/RECOVERY • • • Full coverage by anesthetists and 5 critical care nurses A 6 bed unit with patient nurse ratio of 2:1 when in full capacity All the essential equipment of a first class ICU including ventilators, monitors, defibrillators, perfusers, infusion pumps and other critical care equipment in optimum working condition 5 6/13/2018 LAB, Phisiotherapy and Radiology Manned by qualified biomedical scientists , laboratory technician • Fully automated with capacity to do most investigations • hematological analysis, • serologies ,blood banking and biochemistries. Pharmacy/Nutrition and Dietetics The pharmacy is manned by • • • One (1)Senior Pharmacist and Two (2)Pharmacy Technicians It offers a full complement of various classes of drugs available to patients Staffed by qualified nutritionists/dietician Develops meal plans to suit individual patient needs including nutritional rehabilitation for our malnourished patients 6 6/13/2018 Types of Surgery 5% 22% Spine cases (Degenerative) 15% Spine cases (Deformity) 39% 19% Halo traction Major joint cases Trauma cases COUNTRIES OF ORIGIN OF FOCOS PATIENTS IN-PATIENTS (21 countries) Africa D.R.C Ethiopia Gambia Ghana Liberia Niger Nigeria Sierra Leone Tanzania Togo Uganda Zambia Europe Albania Russia Others Canada China Haiti India Philippines Uruguay USA COUNTRIES OF ORIGIN OF FOCOS PATIENTS SS063 33F Progressive back pain and difficulty standing and walking Tuberculous Spondylitis: 7 6/13/2018 Posterior decompression PLIF PSSI , FOCOS Nutritional Pathways • Nutrition status is a significant factor in the perioperative care of the orthopedic patient • 90% orthopedic patients from Ethiopia seen at the department were undernourished or small for their age • Early identification of patients who are malnourished or at risk is essential which leads to timely nutrition interventions PEDIATRIC PATIENTS CHANGE IN WEIGHT 10.71% 7.14% 42.86% WT GAIN≥1KG WT GAIN≤ 1KG WTMAINTANCE WT LOSS≤1KG 39.29% 8 6/13/2018 FOCOS RISK SCORE FOCOS Traction, Feeding and surgical, program 9 6/13/2018 140° 178° AIS Kyphoscoliosis Severe and rigid 4 months HGT, PSF PCO, Thoracoplasty and SSI Balanced Correction 10 6/13/2018 Dia8YM : NF, Cervical Kyphosis / Dislocation, Quadriplegia ASIA –A C6 level 3 years post op Procedure: ASF C3-C7, Corpectomy C4-C6, Fibular Strut graft C3-C7, Instrumentation C2-T1 11 6/13/2018 ENL968 • • • 57F 12-05-1960 NG A known case of multiple myeloma with Myelopathy She previously had T10 Corpectomy + ASF T9-T11, PSF T7-L1 done in 2015. Two years Post op she was noticed to have collapsed L2 Vertebra and subsequently had Extension of PSF T11-S1. She currently presents with complaints of neck pain and upper back pain as well as occasional numbness in both hands. 2018 Collapsed C3 Treated with PSF C2-T5 • • Patient Details Date Comment Ht (cm) Wt (kg) BMI 09-03-2015 Pre-op WCB WCB WCB 21-09-2015 6 mo 155.3 61.7 25.6 26-09-2016 1 yr 155.3 72.2 29.9 27-06-2017 2 yr 153.5 58.9 25 19-02-2018 3yr 155.3 72.3 30 Oncology Patients • Past Medical History: I. II. III. IV. V. Appendicectomy (1973) 3 Cervical Cerclage T10 Corpectomy + ASF T9-T11, PSF T7-L1 6 Cycle of Chemotherapy for multiple myeloma Hypertensive • Medications: I. II. Exforge 10/160mg Tramadol 2015 2017 12 6/13/2018 2018 Collapsed C3 Op Note: 21-02-18 • • • Diagnosis: Collapsed C2 and T1 Vertebra Procedure: PCF C2-T5, C7/T1 Foraminotomies Bonegraft (Local + Allograft. Complications: None SCOLIOSIS CORRECTION BY REMOTE CONTROL MAGEC: Only Center in West Africa Donation by San Diego Spine Foundation 13 6/13/2018 When Life Throws You a Curve FOCOS will Help Straighten It THANK YOU www.focoshospitalgh.com www.orthofocos.org 14 Spinal Trauma in Tanzania Roger Härtl, MD Professor of Neurosurgery Director of Spinal Surgery Director of the Weill Cornell Center for Comprehensive Spine Care Department of Neurosurgery Weill-Cornell Medical College New York, NY USA “Surgery is the neglected stepchild of global public health” • 45-50 million people – – – – >100 tribes 45% Muslim 45% Christian Tribal religions • Economy – Agriculture, Service industry, mining, industry – Avg. salary $60-70/month 1 Photographs by Andre Liohn Photographs by Andre Liohn 2 3 4 Why Does Surgery Matter? • 5 billion people do not have access to surgical and anaesthesia care • 143 million additional surgical procedures are needed • Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth • Surgery is an “indivisible, indispensable part of health care Questions • • • • • • How can we have an impact from overseas? Limited time – 1 week/year… Limited resources Cultural barriers Language barriers Do our goals, priorities, expectations align? – Who is right, who is wrong? • Fragmented groups in NA & Europe – little coordination • Communication challenges: Equipment, WIFI Weill Cornell Neurosurgery Initiative Definition of achievable goals • To… – assess the current management of neurosurgical diseases – develop a close network that fosters exchange, teaching and communication – train physicians and health care workers in best management practices – implement stepwise and reasonable changes that will improve neurosurgical care 5 7-point SUSTAINABLE Weill Cornell Global Neurosurgery Initiative 1.Yearly visits to teach & train 2.Yearly Neurosurgery symposium in Tanzania 3.Observational fellowship at Weill Cornell: TZ→ Cornell 6 fellows so far 4.One year Global Neurosurgery Fellowship Cornell → TZ 5.Clinical research 6.Weekly Skype conferences 7.Publications Maria Santos Andreas Leidinger • • • • • • 2011 2013 2014 2015 2016 2017 6 Images by Andre Liohn Neurosurgical diseases • Neurotrauma • Spinal infections • Congenital malformations • Hydrocephalus 7 Study Objectives • Prospective collection of data of all spinal trauma admitted to MOI. • To: – – – – Describe the general demographics Understand the overall management and patient flow Identify bottlenecks and critical points Identify deficits and aspects in need of foreign support – Assess surgical outcome Muhimbili Orthopedic Institute (MOI) From 2015-2017 Data Collection Tools 8 Demographics & Epidemiology • n= 180 ST patients collected • GENDER - Male 149 (82.8%) - Female 31 (17.2%) • AGE: 35.7± 12 years old Mechanism of Injury 60 50 40 30 20 10 MVA, 52 1. Falls >3mt, 40 Motorcycle, 29 Pedestrian, 17 Primarily affects young males Falls <3mt, Blunt object, 19 15 Sharp object, Other, 5 3 2. High incidence of falling from heights 0 3. Low incidence of ST secondary to violence Few hospitals Long waiting list Distance Referral time (days) <100km 1 100-200km 7 200-500km 11 36 500-1000km 8 32 1000+km 9 Averange time n 55 Dar es Salaam 2 Regions 5 7.09 Three neurosurgical centers: KMCM (Moshi), Muhimbili (Dar es Salaam) and NED Institute (Zanzibar). Results: Surgery Factors associated with shorter time to surgery ICU Stay (p=0.252) AO Type C (p=0.504) 40% of all patients received surgery. ◦ 45% of all complete injury patients. ◦ 36% of incomplete injury patients. MVA accident as mechanism of injury (p=0.493) Average time to surgery: 28 days. 1. No patient received surgery within 24 hrs. 2. Time to surgery for patients with incomplete injuries was 36 days versus 30 days for those with complete injuries. 3. 90% of incomplete injuries that arrived within 24 hours post trauma did not receive surgery within one week. 9 Results: Primary Outcome Factors related to positive change in AIS Grade Shorter time to surgery •Overall, surgery was the only factor associated with improvement in AIS score from admission to discharge (p<0.003). Surgery (p=0.003) Younger age Falling mechanism <3mts Private insurance AIS Improvement at discharge (p=0.03) Mortality (p=0.007) Surgery Group 21.4% 1.6% Conservative Group 8.2% 16.1% C3-C6 CERVICAL REDUCTION AND FUSION + C4-C6 DECOMPRESSION WITH CORTICAL SCREWS. • Patient was operated 12 days after arrival. • Postoperatively: – Patient kept with soft neck collar – Started physiotherapy 5 days after the surgery • Total admission: 32 days • Complications: NONE • ON DISCHARGE: – ASIA C 10 Costs and Financing • Private patients: 2322.2 USD • Public status: 873.0 USD. • Private patients were more likely to receive surgery (57%) compared to public patients (37.7%, p=0.088). Hospital Bed ICU Bed X-ray CT/MRI Surgical table Lumbar screw (unit) Public 4.47 USD/day 13.40 USD/day 11.17 USD 70-93 USD 89.3 USD 69 USD Private 33.5 USD/day 53.60 USD/day 11.17 USD 70-93 USD 670 USD 69 USD NHIF 2188 USD flat rate inclusive of all expenses (medication, hospital bed, ICU bed, laboratory workups, imaging, surgery, surgical implants and rehabilitation.) Complications • Mortality (8.8%) • Complications: – Pressure ulcers (19.2 %) – Wound infection (2.6 %) Pressure Ulcer Grading 60 47.1 32.4 40 20 11.8 8.8 0 I II III IV Longer waiting lists and lack of human resources contribute to pressure ulcers like this 43 year old male suffering an ASIA A lesion after MVA. • Mortality (%) was associated with cervical injuries (p=0.001) and complete lesions (p=0.016) • Physiotherapy was done for 87.5% of patients. 11 Conclusion • Surgery matters – “Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth” LANCET • Surgical training and education takes time and happens “one-on-one” • Identify champion surgeons • Weill Cornell Neurosurgery SUSTAINABLE Model To Maximize impact: 1. 2. 3. 4. 5. Regular visits Courses Permanent fellowships in TZ 3 months fellowships in NYC Research: 1. collect data and measure impact 6. Skype calls: communication 7. Publications http://weillcornellbrainandspine.org/tanzania 12
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