Pediatric Surgical Needs And Barriers In Access To Care In Middle Eastern Refugee Families: A Mixed-Methods Study

Ongoing international conflicts have displaced 80 million people, with over 500,000 resettling in the United States (US). Approximately half (53%) of these are children. Reports from Middle Eastern conflict areas and surveys of refugees arriving in Europe have highlighted increased pediatric surgical burden in refugees. However, surgical conditions and barriers to access in refugee children after resettlement in the US remain largely understudied. This mixed-methods study aimed to quantify the pediatric surgical needs of refugee children resettled in Southern Connecticut, and to explore the factors, facilitators, and barriers that impact Middle Eastern refugee families’ experiences with pediatric surgical care. A two-phase explanatory mixed-methods design featured a quantitative retrospective cohort study within a hospital-network covering Southern Connecticut between 09/01/2009-09/27/2019 of all refugee children younger than 18 years old, followed by a qualitative investigation informed by and designed to explain the trends in the first phase. The quantitative component compared demographics, surgical referrals, incidence of surgical diseases, and pre-operative and post-operative encounters between refugee children and all pediatric patients within the network. The qualitative phase included semi-structured video or phone interviews conducted in English, Pashto, or Arabic with parents of children who underwent surgery, women who sought prenatal surgery consultation, and refugee providers. Interviews were analyzed for core themes and coded using an integrated approach. In the quantitative phase, 1211 refugee children were identified. The need for some operative intervention in refugee children (21.2%) was nearly twice that of children (11.6%) within the network (p\u3c0.0001). Almost half (45.0%) of refugees required postoperative admissions, compared to 32.2% of the general population (p\u3c0.0001). Dental procedures were the most common. Compared to the general population, refugees also carried a higher incidence of circumcision (Incidence Ratio [IR] of 4.73, 95% Confidence Interval [95%CI]: 3.202-6.953, p\u3c0.0001), spinal fusion (IR: 136.4, 95%CI: 58.86-315.6, p\u3c0.0001), inguinal hernia repairs (IR: 2.05, 95%CI: 1.114-3.764, p=0.0350), myringotomy (IR: 7.24, 95%CI: 3.296-15.84, p=0.0002), liver transplants (IR:51.08, 95%CI: 24.81-104.9, p\u3c0.0001), and congenital diaphragmatic hernia repairs (IR:30.86, 95%CI: 8.083-117.5, p=0.0023). Refugee families cancelled 17.7% appointments before and 31.3% within the year after surgery (p\u3c0.0001), and never arrived at 7.2% before and 11.1% within the year after surgery (p\u3c0.0001). The quantitative phase of the study identified four major themes impacting refugee families’ experiences with pediatric surgery: (1) medical navigation and illness experiences, (2) personal support systems, (3) structural determinants of health, and (4) the COVID-19 pandemic. Each theme included multiple barriers and facilitators for refugee families while accessing surgery. Notable subthemes were language and immigration experiences as structural determinants of health; the support of faith, family, friends, and community, balanced with privacy concerns among personal support systems; and communication between the care team and the family as it relates to cultural humility. This work demonstrates that while refugee children were more likely to require operative procedures and post-operative hospital admissions than the general population, they were less likely to comply with suggested post-operative follow-up. As such, our qualitative findings highlight important barriers and facilitators that may lead to these epidemiologic trends and elucidate actionable steps for improving surgical care access for refugee families resettled in the US

Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study

OBJECTIVES: Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. DESIGN: A multicentre, international, collaborative cohort study. SETTING: 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. PARTICIPANTS: Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. MAIN OUTCOME MEASURE: All-cause mortality at 30 days and 90 days. RESULTS: 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). CONCLUSIONS: The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally

Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care