Publications by authors named "Tu M Tran"

19 Publications

  • Page 1 of 1

Cancer-Associated Retinopathy due to Clear Cell Renal Carcinoma.

Ocul Oncol Pathol 2021 Mar 18;7(1):31-35. Epub 2020 Dec 18.

Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, USA.

An 84-year-old female presented with bilateral scotomas and progressive nyctalopia over 1 year. Best-corrected visual acuity was 20/50 in both eyes with reduced color vision. Goldmann visual field showed bilateral cecocentral scotomas and generalized constriction of the visual fields. This led to an electroretinogram showing an electronegative pattern consistent with autoimmune retinopathies. Infectious workup was negative. Anti-retinal antibodies were positive, leading to a presumed diagnosis of cancer-associated retinopathy (CAR). Imaging showed a previously unknown left renal lower pole mass, and she underwent a radical nephrectomy. Biopsy showed nuclear grade-3 clear cell renal carcinoma staged T1. The patient was treated with oral prednisone with no ocular improvement. We report on a rare case of clear cell renal carcinoma causing CAR. CAR is an important paraneoplastic syndrome to diagnose since the majority of ocular cases precede other manifestations of malignancy. Therefore, a timely diagnosis of CAR can be lifesaving or at least life-extending.
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http://dx.doi.org/10.1159/000511189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989776PMC
March 2021

Smartphone-based Ophthalmic Imaging Compared With Spectral-domain Optical Coherence Tomography Assessment of Vertical Cup-to-disc Ratio Among Adults in Southwestern Uganda.

J Glaucoma 2021 Mar;30(3):e90-e98

Department of Ophthalmology, Mbarara University of Science and Technology.

Precis: Using optical coherence tomography (OCT) measurements as a reference standard for vertical cup-to-disc ratio (vCDR), a smartphone-based ophthalmic camera has a sensitivity of 67.7% and specificity of 96.7% to detect a vCDR>0.5.

Purpose: The purpose of this study was to assess the performance of a smartphone-based ophthalmic camera system using an Apple iPhone 6S and an adapter, Paxos Scope, to obtain adequate dilated fundus photos to measure clinically useful vCDR cutoffs.

Patients And Methods: Adult patients from a government tertiary level eye hospital in Southwestern Uganda were prospectively recruited from January to April 2019. All patients experienced a comprehensive eye examination, dilated posterior segment indirect ophthalmoscope imaging with the Paxos Scope, and spectral-domain OCT imaging with a Cirrus HD-OCT to measure vCDR. Patients' eyes excluded had media opacities or existing disease precluding a view of the fundus. Fundus images underwent a single masked review to assign vCDR at increments of 0.1. Descriptive statistics, parametric and χ2 tests for significance, repeated measures correlation, κ, receiver operating characteristics curve, and Bland-Altman were used to assess the data.

Results: Among 467 (consecutive) individuals, fundus photographs acquired with the Paxos Scope demonstrated a 67.7% [95% confidence interval (CI), 63.0-72.0] sensitivity and 96.7% (95% CI, 94.2-98.3) specificity to detect a vCDR>0.5, using OCT as the reference standard. A total of 138 eyes were excluded due to poor imaging acquisition, such as dense cataract, rendering 796 eyes for analysis. The vCDR from graded Paxos Scope images and OCT correlated well with repeated measures correlation of 0.82 (95% CI, 0.77-0.86, P<0.001) and agreement, dichotomized as >0.5 or ≤0.5, was 80.9% (κ=0.63±0.034, P<0.001). Among glaucoma and glaucoma suspects (85 eyes), the sensitivity and specificity dichotomized using vCDR>0.5 were 97.5% (95% CI, 91.3-99.7) and 80.0% (95% CI, 28.4-99.5), respectively. The area under the receiver operating characteristics curve was 0.92 (95% CI, 0.89-0.94) for all eyes and 0.98 (95% CI, 0.78-1.0) for glaucoma and glaucoma suspects.

Conclusions: The Paxos Scope produced images that can be reliably used to estimate vCDR, which is closely aligned with the automated algorithm from the OCT optic disc cube scan. The low-cost, ready-to-integrate adapter, and minimal training requirements make it a viable option for population-based screening in low-resource settings.
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http://dx.doi.org/10.1097/IJG.0000000000001779DOI Listing
March 2021

Quantitative Fundus Autofluorescence in Rhesus Macaques in Aging and Age-Related Drusen.

Invest Ophthalmol Vis Sci 2020 07;61(8):16

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Purpose: To employ quantitative fundus autofluorescence (qAF) imaging in rhesus macaques to noninvasively assess retinal pigment epithelial (RPE) lipofuscin in nonhuman primates (NHPs) as a model of aging and age-related macular degeneration (AMD).

Methods: The qAF imaging was performed on eyes of 26 rhesus macaques (mean age 18.8 ± 8.2 years, range 4-27 years) with normal-appearing fundus or with age-related soft drusen using a confocal scanning laser ophthalmoscope with 488 nm excitation and an internal fluorescence reference. Eyes with soft drusen also underwent spectral-domain optical coherence tomography imaging to measure drusen volume and height of individual drusen lesions. The qAF levels were measured from the perifoveal annular ring (quantitative autofluorescence 8 [qAF8]) using the Delori grid, as well as focally over individual drusen lesions in this region. The association between qAF levels and age, sex, and drusen presence and volume were determined using multivariable regression analysis.

Results: Mean qAF levels increased with age (P < 0.001) and were higher in females (P = 0.047). Eyes with soft drusen exhibited reduced mean qAF compared with age-matched normal eyes (P = 0.003), with greater drusen volume showing a trend toward decreased qAF levels. However, qAF levels are focally increased over most individual drusen (P < 0.001), with larger drusen appearing more hyperautofluorescent (R2 = 0.391, P < 0.001).

Conclusions: In rhesus macaques, qAF levels are increased with age and female sex, but decreased in eyes with soft drusen, similar to human AMD. However, drusen lesions appear hyperautofluorescent unlike those in humans, suggesting similarities and differences in RPE lipofuscin between humans and NHPs that may provide insight into drusen biogenesis and AMD pathogenesis.
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http://dx.doi.org/10.1167/iovs.61.8.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425688PMC
July 2020

Corneal Blindness in Asia: A Systematic Review and Meta-Analysis to Identify Challenges and Opportunities.

Cornea 2020 Sep;39(9):1196-1205

Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Purpose: To describe the causes and prevalence of moderate-to-severe visual impairment (MSVI) and blindness from corneal diseases, as well as corneal transplantation across Asia.

Methods: A meta-analysis of the published literature to identify population-based surveys conducted from 2008 to 2019 in 22 Asian countries regarding the prevalence and causes of MSVI and blindness from corneal disease, and a review of national corneal transplant data and eye bank statistics.

Results: A total of 5307 records were screened to identify 57 reports that were used to estimate a prevalence of MSVI and blindness caused by corneal diseases in Asia of 0.38% (95% confidence interval, 0.29%-0.48%). The most frequent corneal diseases were infectious keratitis, trauma, and pseudophakic bullous keratopathy. As expected, these represented the most common indications for corneal transplantation, although the percentages in each country differed based on the level of economic development, with pseudophakic bullous keratopathy being the most common indication in countries with higher gross national income per capita. Despite this, endothelial keratoplasty is not the most commonly performed form of corneal transplantation in any Asian country and represents only a small percentage of keratoplasty procedures performed in most countries.

Conclusions: The prevalence of MSVI and blindness from corneal disease in Asia is approximately 0.4%, with a nearly 20-fold difference in the national prevalence across the region. The indications for keratoplasty, reflective of the causes of corneal dysfunction, also vary, more so according to the gross national income than to geographic location, and only a few Asian countries have rates of corneal transplantation above international means.
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http://dx.doi.org/10.1097/ICO.0000000000002374DOI Listing
September 2020

Presumed mast cell choroidal infiltrate in aggressive systemic mastocytosis.

Am J Ophthalmol Case Rep 2020 Jun 4;18:100614. Epub 2020 Feb 4.

Department of Ophthalmology and Visual Neuroscience, University of Minnesota, Minneapolis, MN, USA.

Purpose: To report a rare case of a unilateral choroidal mast cell infiltration in a patient with aggressive systemic mastocytosis (ASM).

Observations: The patient is a man in his fifties with a diagnosis of ASM. He developed visual complaints in the right eye associated with an area of subretinal fluid on fundus examination. Visual acuity at presentation was 20/150 in the right eye and 20/25 in the left eye. After ophthalmic and radiologic imaging workup, the patient was diagnosed with presumed choroidal mast cell infiltrate. The index of suspicion was high due to the prior ASM diagnosis. External beam radiation and intravitreal injection treatments were offered but the patient declined. The patient was switched from interferon to a new targeted systemic therapy for ASM, midostaurin. Despite some mixed, temporary response in systemic symptoms/signs of ASM at four months, the choroidal lesion and subretinal fluid were stable with visual acuity at 20/125.

Conclusion And Importance: Mast cell choroidal infiltration in ASM should be considered as part of the differential with acute/subacute vision changes. Diagnosis requires exclusion of other possibilities with ocular imaging and in this case, monitoring for development of other malignancies in which there were none. Midostaurin's ocular response was not on par with systemic response. Additional localized ocular therapies may be required.
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http://dx.doi.org/10.1016/j.ajoc.2020.100614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021538PMC
June 2020

Surgical need among the ageing population of Uganda.

Afr Health Sci 2019 Mar;19(1):1778-1788

Makerere University College of Health Sciences, Department of Anatomy, Kampala, Uganda P. O. Box 7072, New Mulago Hospital Complex Kampala, Uganda.

Background: Uganda's ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown.

Objectives: To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions.

Methods: A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation.

Results: The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes.

Conclusion: There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed.
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http://dx.doi.org/10.4314/ahs.v19i1.54DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531960PMC
March 2019

Diagnosis and Management of Trochleodynia, Trochleitis, and Trochlear Headache.

Front Neurol 2019 12;10:361. Epub 2019 Apr 12.

Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, United States.

Migraine and tension-type headaches (TTHs) comprise a significant burden of neurological disease globally. Trochleodynia, also known as primary trochlear headache or trochleitis, may go unrecognized and contribute to worsening of these headache disorders. It may also present in isolation. We review the English literature on this under-recognized condition and describe what is known about the theorized pathophysiology, clinical presentation, and differential diagnosis. We also present a management algorithm for patients presenting with trochleodynia.
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http://dx.doi.org/10.3389/fneur.2019.00361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6473032PMC
April 2019

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

Ann Glob Health 2019 04 1;85(1). Epub 2019 Apr 1.

University of Minnesota Department of Surgery, Minneapolis, MN, US.

Background: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce.

Objective: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda.

Methods: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda).

Findings: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated.

Conclusions: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.
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http://dx.doi.org/10.5334/aogh.2427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6634461PMC
April 2019

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey.

World Neurosurg 2018 Feb 24;110:e747-e754. Epub 2017 Nov 24.

Duke University Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, USA; Duke University Global Health Institute, Duke University Medical Center, Durham, North Carolina, USA.

Background: The Surgeons OverSeas Assessment of Surgical Need tool (SOSAS) was created to evaluate the burden of surgically treatable conditions in low- and middle-income countries. The goal of our study is to describe the face, head, and neck (FHN) conditions that need surgical care in Uganda, along with barriers to that care and disability from these conditions.

Methods: A 2-stage cluster randomized SOSAS survey was administered in a cross-sectional manner between August and September 2014. Participants included randomly selected persons in 105 enumeration areas in 74 districts throughout Uganda with 24 households in each cluster. The SOSAS survey collected demographic and clinical data on all respondents. Univariate and multivariate logistic models evaluated associations of demographic characteristics and clinical characteristics of the FHN conditions and outcomes of whether health care was sought or surgical care was received.

Results: Of the 4428 respondents, 331 (7.8%) reported having FHN conditions. The most common types of conditions were injury-related wounds. Of those who reported an FHN condition, 36% reported receiving no surgical care whereas 82.5% reported seeking health care. In the multivariate model, literacy and type of condition were significant predictors of seeking health care whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care.

Conclusions: Many individuals in Uganda are not receiving surgical care and barriers include costs, rural residency, and literacy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery and expand surgical capacity.
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http://dx.doi.org/10.1016/j.wneu.2017.11.099DOI Listing
February 2018

Geospatial analysis of unmet pediatric surgical need in Uganda.

J Pediatr Surg 2017 Oct 31;52(10):1691-1698. Epub 2017 Mar 31.

Duke University Global Health Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA; Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA; Duke University Division of Global Neurosurgery and Neurology, Durham, NC, USA.

Background: In low- and middle-income countries (LMICs), an estimated 85% of children do not have access to surgical care. The objective of the current study was to determine the geographic distribution of surgical conditions among children throughout Uganda.

Methods: Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 2176 children in 2315 households throughout Uganda. At the district level, we determined the spatial autocorrelation of surgical need with geographic access to surgical centers variable.

Findings: The highest average distance to a surgical center was found in the northern region at 14.97km (95% CI: 11.29km-16.89km). Younger children less than five years old had a higher prevalence of unmet surgical need in all four regions than their older counterparts. The spatial regression model showed that distance to surgical center and care availability were the main spatial predictors of unmet surgical need.

Interpretation: We found differences in unmet surgical need by region and age group of the children, which could serve as priority areas for focused interventions to alleviate the burden. Future studies could be conducted in the northern regions to develop targeted interventions aimed at increasing pediatric surgical care in the areas of most need.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.03.045DOI Listing
October 2017

Epidemiology of pediatric surgical needs in low-income countries.

PLoS One 2017 3;12(3):e0170968. Epub 2017 Mar 3.

Duke University Global Health Institute, Durham, NC, United States of America.

Objective: According to recent estimates, at least 11% of the total global burden of disease is attributable to surgically-treatable diseases. In children, the burden is even more striking with up to 85% of children in low-income and middle-income countries (LMIC) having a surgically-treatable condition by age 15. Using population data from four countries, we estimated pediatric surgical needs amongst children residing in LMICs.

Methods: A cluster randomized cross-sectional countrywide household survey (Surgeons OverSeas Assessment of Surgical Need) was done in four countries (Rwanda, Sierra Leone, Nepal and Uganda) and included demographics, a verbal head to toe examination, and questions on access to care. Global estimates regarding surgical need among children were derived from combined data, accounting for country-level clustering.

Results: A total of 13,806 participants were surveyed and 6,361 (46.1%) were children (0-18 years of age) with median age of 8 (Interquartile range [IQR]: 4-13) years. Overall, 19% (1,181/6,361) of children had a surgical need and 62% (738/1,181) of these children had at least one unmet need. Based on these estimates, the number of children living with a surgical need in these four LMICs is estimated at 3.7 million (95% CI: 3.4, 4.0 million). The highest percentage of unmet surgical conditions included head, face, and neck conditions, followed by conditions in the extremities. Over a third of the untreated conditions were masses while the overwhelming majority of treated conditions in all countries were wounds or burns.

Conclusion: Surgery has been elevated as an "indivisible, indispensable part of health care" in LMICs and the newly formed 2015 Sustainable Development Goals are noted as unachievable without the provision of surgical care. Given the large burden of pediatric surgical conditions in LMICs, scale-up of services for children is an essential component to improve pediatric health in LMICs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170968PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5336197PMC
August 2017

Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional, household survey.

Pediatr Surg Int 2016 Nov 10;32(11):1075-1085. Epub 2016 Sep 10.

Duke University Global Health Institute, 310 Trent Drive, Durham, NC, 27710, USA.

Purpose: Little is known about the prevalence of pediatric surgical conditions in low- and middle-income countries. Many children never seek medical care, thus the true prevalence of surgical conditions in children in Uganda is unknown. The objective of this study was to determine the prevalence of surgical conditions in children in Uganda.

Methods: Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 4248 individuals in 2315 households in 105 randomly selected clusters throughout Uganda. Children aged 0-18 were included if randomly selected from the household; for those who could not answer for themselves, parents served as surrogates.

Results: Of 2176 children surveyed, 160 (7.4 %) reported a currently untreated surgical condition. Lifetime prevalence of surgical conditions was 14.0 % (305/2176). The predominant cause of surgical conditions was trauma (48.4 %), followed by wounds (19.7 %), acquired deformities (16.2 %), and burns (12.5 %). Of 90 pediatric household deaths, 31.1 % were associated with a surgically treatable proximate cause of death (28/90 deaths).

Conclusion: Although some trauma-related surgical burden among children can be adequately addressed at district hospitals, the need for diagnostics, human resources, and curative services for more severe trauma cases, congenital deformities, and masses outweighs the current capacity of hospitals and trained pediatric surgeons in Uganda.
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http://dx.doi.org/10.1007/s00383-016-3957-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050237PMC
November 2016

Burden of Surgical Conditions in Uganda: A Cross-sectional Nationwide Household Survey.

Ann Surg 2017 08;266(2):389-399

*Duke University Division of Global Neurosurgery and Neuroscience, Durham, NC †Duke University Medical School, Durham, NC ‡Department of Surgery, University of Washington, Seattle, WA §Makerere University School of Public Health, Kampala, Uganda ¶Department of Anatomy, Makerere University School of Medicine, Kampala, Uganda ||Uganda Bureau of Statistics, Kampala, Uganda **Department of Surgery, University of Minnesota, Minneapolis, MN ††Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda ‡‡Department of Neurosurgery, Duke University, Durham, NC.

Objective: To quantify the burden of surgical conditions in Uganda.

Background: Data on the burden of disease have long served as a cornerstone to health policymaking, planning, and resource allocation. Population-based data are the gold standard, but no data on surgical burden at a national scale exist; therefore, we adapted the Surgeons OverSeas Assessment of Surgical Need survey and conducted a nation-wide, cross-sectional survey of Uganda to quantify the burden of surgically treatable conditions.

Methods: The 2-stage cluster sample included 105 enumeration areas, representing 74 districts and Kampala Capital City Authority. Enumeration occurred from August 20 to September 12, 2014. In each enumeration area, 24 households were randomly selected; the head of the household provided details regarding any household deaths within the previous 12 months. Two household members were randomly selected for a head-to-toe verbal interview to determine existing untreated and treated surgical conditions.

Results: In 2315 households, we surveyed 4248 individuals: 461 (10.6%) reported 1 or more conditions requiring at least surgical consultation [95% confidence interval (CI) 8.9%-12.4%]. The most frequent barrier to surgical care was the lack of financial resources for the direct cost of care. Of the 153 household deaths recalled, 53 deaths (34.2%; 95% CI 22.1%-46.3%) were associated with surgically treatable signs/symptoms. Shortage of time was the most frequently cited reason (25.8%) among the 11.6% household deaths that should have, but did not, receive surgical care (95% CI 6.4%-16.8%).

Conclusions: Unmet surgical need is prevalent in Uganda. There is an urgent need to expand the surgical care delivery system starting with the district-level hospitals. Routine surgical data collection at both the health facility and household level should be implemented.
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http://dx.doi.org/10.1097/SLA.0000000000001970DOI Listing
August 2017

Geospatial Analysis of Unmet Surgical Need in Uganda: An Analysis of SOSAS Survey Data.

World J Surg 2017 Feb;41(2):353-363

Division of Duke Global Neurosurgery and Neuroscience, Department of Neurosurgery, Duke University Medical Center, 4508 Hospital South, Durham, NC, 27710, USA.

Background: Globally, a staggering five billion people lack access to adequate surgical care. Sub-Saharan Africa represents one of the regions of greatest need. We sought to understand how geographic factors related to unmet surgical need (USN) in Uganda.

Methods: We performed a geographic information system analysis of a nationwide survey on surgical conditions performed in 105 enumeration areas (EAs) representing the national population. At the district level, we determined the spatial autocorrelation of the following study variables: prevalence of USN, hub distance (distance from EA to the nearest surgical center), area of coverage (geographic catchment area of each center), tertiary facility transport time (average respondent-reported travel time), and care availability (rate of hospital beds by population and by district). We then used local indicators of spatial association (LISA) and spatial regression to identify any significant clustering of these study variables among the districts.

Results: The survey enumerated 4248 individuals. The prevalence of USN varied from 2.0-45 %. The USN prevalence was highest in the Northern and Western Regions. Moran's I bivariate analysis indicated a positive correlation between USN and hub distance (p = 0.03), area of coverage (p = 0.02), and facility transport time (p = 0.03). These associations were consistent nationally. The LISA analysis showed a high degree of clustering among sets of districts in the Northern Sub-Region.

Conclusions: This study demonstrates a statistically significant association between USN and the geographic variables examined. We have identified the Northern Sub-Region as the highest priority areas for financial investment to reduce this unmet surgical disease burden.
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http://dx.doi.org/10.1007/s00268-016-3689-5DOI Listing
February 2017

Surgeons OverSeas Assessment of Surgical Need (SOSAS) Uganda: Update for Household Survey.

World J Surg 2015 Dec;39(12):2900-7

Duke University Global Health Institute, Durham, NC, USA.

Introduction: The first step in improving surgical care delivery in low- and middle-income countries (LMICs) is quantifying surgical need. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a validated household survey that has been previously implemented in three LMICs with great success. We implemented the SOSAS survey in Uganda, a medium-sized country with comparatively more language and ethnic group diversity.

Methods: The investigators partnered with the Performance Monitoring and Accountability 2020 (PMA2020) Uganda to access a data collection platform sampling 2520 households in 105 randomly selected enumeration areas. Due to geographic size consideration and language diversity, SOSAS's methodology was updated in three significant dimensions (1) technology, (2) staff management, and (3) questionnaire adaptations.

Results: The SOSAS survey was successfully implemented with non-medically trained but field proven research assistants. We sampled 2315 of 2402 eligible households (response rate 96.4 %) and 4248 of 4374 eligible individual respondents (response rate 97.1 %). The female-to-male ratio was 51.1-48.9 %. Total survey cost was USD 73,145 and data collection occurred in 14 days.

Discussion: SOSAS Uganda has demonstrated that non-medically trained, but university-educated, experienced researchers supervised by academic surgeons can successfully perform accurate data collection of SOSAS. SOSAS can be successfully implemented within larger and more diverse LMICs using existing national survey platforms, and SOSAS Uganda provides insights on how SOSAS can be executed specifically within other PMA2020 program countries.
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http://dx.doi.org/10.1007/s00268-015-3191-5DOI Listing
December 2015

Pilot study of a population-based survey to assess the prevalence of surgical conditions in Uganda.

Surgery 2015 Sep 16;158(3):764-72. Epub 2015 Jun 16.

Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda. Electronic address:

Background: Noncommunicable diseases, including those requiring surgical care, are increasingly straining low- and middle-income countries. Globally, 11% of all disability-adjusted life-years lost result from conditions requiring surgery; however, little is known about country-specific burden. We piloted a household-based survey in a periurban district of Uganda to estimate the prevalence of surgical conditions and to identify logistical challenges.

Methods: Our sample comprised 57 households in 5 enumeration areas in the Wakiso District, in central Uganda. Our survey tool was the Surgeons OverSeas Assessment of Surgical need. A household representative completed demographic and household death information, and 2 randomly selected household members completed questions on surgical conditions.

Results: Of 96 participants, 6 (6.3%; 95% CI, 2.3-13.1) had an existing, untreated surgical condition. The lifetime prevalence of surgical conditions was 26% (25/96). The most common barrier to access to care was lack of financial resources. Of the 3 deaths reported, 2 were associated with surgery. The mean household interview time was 36 minutes. The greatest challenge was efficient coordination with local team members and government officials.

Conclusion: In this setting, the current prevalence of surgical conditions was nearly 1 in 10 persons, and lifetime occurrence was high, at 1 in 4 persons. Addressable challenges led to question revisions and a change in the data collection platform. A full-country study is both feasible and necessary to characterize the met and unmet need for surgical care in Uganda.
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http://dx.doi.org/10.1016/j.surg.2015.05.011DOI Listing
September 2015

Estimation of Surgery Capacity in Haiti: Nationwide Survey of Hospitals.

World J Surg 2015 Sep;39(9):2182-90

University of California Haiti Initiative, Los Angeles, CA, USA.

Background: Haiti's surgical capacity was significantly strained by the 2010 earthquake. As the government and its partners rebuild the health system, emergency and essential surgical care must be a priority.

Methods: A validated, facility-based assessment tool developed by WHO was completed by 45 hospitals nationwide. The hospitals were assessed for (1) infrastructure, (2) human resources, (3) surgical interventions and emergency care, and (4) material resources for resuscitation. Fisher's exact test was used to compare hospitals by sectors: public compared to private and mixed (public-private partnerships).

Results: The 45 hospitals included first-referral level to the national referral hospital: 20 were public sector and 25 were private or mixed sector. Blood banks (33% availability) and oxygen concentrators (58%) were notable infrastructural deficits. For human resources, 69% and 33% of hospitals employed at least one full-time surgeon and anaesthesiologist, respectively. Ninety-eight percent of hospitals reported capacity to perform resuscitation. General and obstetrical surgical interventions were relatively more available, for example 93% provided hernia repairs and 98% provided cesarean sections. More specialized interventions were at a deficit: cataract surgery (27%), cleft repairs (31%), clubfoot (42%), and open treatment of fractures (51%).

Conclusion: Deficiencies in infrastructure and material resources were widespread and should be urgently addressed. Physician providers were mal-distributed relative to non-physician providers. Formal task-sharing to midlevel and general physician providers should be considered. The parity between public and private or mixed sector hospitals in availability of Ob/Gyn surgical interventions is evidence of concerted efforts to reduce maternal mortality. This ought to provide a roadmap for strengthening of surgical care capacity.
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http://dx.doi.org/10.1007/s00268-015-3089-2DOI Listing
September 2015

Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda.

World Neurosurg 2015 Mar 19;83(3):269-77. Epub 2014 Dec 19.

Duke University Global Health Institute, Durham, North Carolina, USA; Division of Neurosurgery, Department of Surgery, Duke University, Durham, North Carolina, USA. Electronic address:

Objective: Road traffic accidents are a leading cause of injury in low- and middle-income countries, where mortality rates are disproportionately higher. Patients with severe traumatic brain injury (TBI) tend to have very poor outcomes. To reduce the burden from severe TBI, we describe its distribution at Mulago National Referral Hospital (Kampala, Uganda) and identify the associations between outcomes and patient characteristics, offering insights into prevention and future research efforts to improve clinical care.

Methods: This is a single-institution, retrospective chart review including patients of all ages with a Glasgow Coma Scale (GCS) score of 8 or less (measured upon admission). A database was compiled to maximize all available clinical variables. Descriptive statistics and univariable and multivariable regression models were fitted to identify significant associations with outcome (died or discharged).

Results: One hundred twenty patients were identified between July 1, 2008, and June 30, 2009. The cumulative incidence of admissions is 89 per 100,000. Thirty-one patients died in the hospital, yielding a 25.8% mortality rate. Motorcycle road traffic accident was the leading mechanism of injury, and males ages 15-29 years comprised the predominant demographic (42.5% of patients). Initial GCS, change in GCS score during hospital stay, and the presence of hematoma were strongest predictors of outcome.

Conclusions: Severe TBI was a common condition for injury-related hospital admissions at Mulago Hospital. The capacity for neurosurgery may have explained the relatively lower mortality rate than previously reported from Sub-Saharan Africa. Further investigations are needed. Targeted prevention programs focused on motorcycle users and helmet law enforcement should decrease the incidence of severe TBI.
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http://dx.doi.org/10.1016/j.wneu.2014.12.028DOI Listing
March 2015

Non-tuberculous mycobacterial infections at San Francisco General Hospital.

Clin Respir J 2015 Oct 10;9(4):436-42. Epub 2014 Jun 10.

Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA.

Background And Aims: The epidemiology of non-tuberculous mycobacteria (NTM) infection is not well defined. We evaluated the trends in incidence of NTM infections at San Francisco General Hospital (SFGH), a large metropolitan county hospital.

Methods: We performed a retrospective review of microbiologic and clinical records of all patients with a positive NTM culture reported from 1993 to 2001. NTM infection was defined by the isolation of >1 NTM from any clinical specimen. Patients were stratified by human immunodeficiency virus (HIV) status. Univariate and multivariate logistic regression were used to identify factors that were independently associated with NTM infection. Trends over time were assessed using Poisson test for trend.

Results: During the study period, 25 736 samples from 7395 patients were cultured for mycobacteria. Of these samples, 2853 (11.1%) from 1345 patients (18.2%) were culture positive for NTM. Patient characteristics associated with infection included younger age (P < 0.001), male gender (P < 0.001), White ethnicity compared with Asian and Hispanic (P < 0.001 and P = 0.01, respectively), and HIV positivity (P < 0.001). Overall, NTM infection at SFGH decreased significantly from 319 cases in 1993 to 59 in 2001 (P < 0.001). Mycobacterium avium was predominant in both HIV-positive and HIV-negative populations (74.5% and 44.6% of isolates, respectively), and Mycobacterium kansasii was the second most common NTM species isolated. The proportion of other NTM species isolated in these groups differed.

Conclusion: In contrast to other published studies, time-series analyses show that NTM isolation rates decreased during the study period at SFGH, where NTM was most strongly associated with HIV infection.
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October 2015