Task-sharing spinal anaesthesia care in three rural Indian hospitals: a non-inferiority randomised controlled clinical trial.

BACKGROUND: Task-sharing of spinal anaesthesia care by non-specialist graduate physicians, termed medical officers (MOs), is commonly practised in rural Indian healthcare facilities to mitigate workforce constraints. We sought to assess whether spinal anaesthesia failure rates of MOs were non-inferior to those of consultant anaesthesiologists (CA) following a standardised educational curriculum. METHODS: We performed a randomised, non-inferiority trial in three rural hospitals in Tamil Nadu and Chhattisgarh, India. Patients aged over 18 years with low perioperative risk (ASA I & II) were randomised to receive MO or CA care. Prior to the trial, MOs underwent task-based anaesthesia training, inclusive of remotely accessed lectures, simulation-based training and directly observed anaesthetic procedures and intraoperative care. The primary outcome measure was spinal anaesthesia failure with a non-inferiority margin of 5%. Secondary outcome measures consisted of incidence of perioperative and postoperative complications. FINDINGS: Between 12 July 2019 and 8 June 2020, a total of 422 patients undergoing surgical procedures amenable to spinal anaesthesia care were randomised to receive either MO (231, 54.7%) or CA care (191, 45.2%). Spinal anaesthesia failure rate for MOs (7, 3.0%) was non-inferior to those of CA (5, 2.6%); difference in success rate of 0.4% (95% CI=0.36-0.43%; p=0.80). Additionally, there were no statistically significant differences observed between the two groups for intraoperative or postoperative complications, or patients' experience of pain during the procedure. INTERPRETATION: This study demonstrates that failure rates of spinal anaesthesia care provided by trained MOs are non-inferior to care provided by CAs in low-risk surgical patients. This may support policy measures that use task-sharing as a means of expanding anaesthesia care capacity in rural Indian hospitals. TRIAL REGISTRATION NUMBER: NCT04438811.

A machine learning model to predict the need for conversion of operative approach in patients undergoing colectomy for neoplasm.

BACKGROUND: Studies comparing conversion from laparoscopic to open approaches to colectomy have found an association between conversion and morbidity, mortality, and length of stay, suggesting that certain patients may benefit from an open approach "up-front." AIM: The objective of this study was to use machine learning algorithms to develop a model enabling the prediction of which patients are likely to require conversion. METHODS AND RESULTS: We used ACS NSQIP data to identify patients undergoing colectomy (2014-2019). We included patients undergoing elective colectomy for colorectal neoplasm via a minimally invasive approach or a converted approach. The outcome of interest was conversion. Variables were included in the model based on their correlation with conversion by logistic regression (p < .05). Two models were used: weighted logistic regression with regularization, and Random Forest classifier. The data was randomly split into training (70%) and test (30%) cohorts, and prediction performance was calculated. 24 327 cases were included (17 028 training, 7299 test). When applied to the test cohort, the models had an accuracy of 0.675 (range 0.65-0.70) in predicting conversion; c-index ranged from 0.62-0.63. This machine learning model achieved a moderate area under the curve and a high negative predictive value, but a low positive predictive value; therefore, this model can predict (with 95% accuracy) whether a colectomy for neoplasm can be successfully completed using a minimally invasive approach. CONCLUSION: This model can be used to reassure surgeons of the appropriateness of a minimally invasive approach when planning for an elective colectomy.

Evaluation of Financial Relationships Between US Colorectal Surgery Fellowship Program Directors and Industry.

This cross-sectional study evaluates the financial relationships between colorectal surgery fellowship program directors and industry.

Evaluating the Accuracy and Design of Visual Abstracts in Academic Surgical Journals.

OBJECTIVE: The objective of this study was to assess the quality and accuracy of visual abstracts published in academic surgical journals. BACKGROUND: Visual abstracts are commonly used to disseminate medical research findings. They distill the key messages of a research article, presenting them graphically in an engaging manner so that potential readers can decide whether to read the complete manuscript. METHODS: We developed the Visual Abstract Assessment Tool based upon published guidelines. Seven reviewers underwent iterative training to apply the tool. We collected visual abstracts published by 25 surgical journals from January 2017 to April 2021; those corresponding to systematic reviews without meta-analysis, conference abstracts, narrative reviews, video abstracts, or nonclinical research were excluded. Included visual abstracts were scored on accuracy (as compared with written abstracts) and design, and were given a "first impression" score. RESULTS: Across 25 surgical journals 1325 visual abstracts were scored. We found accuracy deficits in the reporting of study design (35.8%), appropriate icon use (49%), and sample size reporting (69.2%), and design deficits in element alignment (54.8%) and symmetry (36.1%). Overall scores ranged from 9 to 14 (out of 15), accuracy scores from 4 to 8 (out of 8), and design scores from 3 to 7 (out of 7). No predictors of visual abstract score were identified. CONCLUSION: Visual abstracts vary widely in quality. As visual abstracts become integrated with the traditional components of scientific publication, they must be held to similarly high standards. We propose a checklist to be used by authors and journals to standardize the quality of visual abstracts.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery.

OBJECTIVES: To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system. DESIGN: An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations. SETTING: Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities. PARTICIPANTS: All operative patients in Mongolia's public hospitals, 2006-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality. RESULTS: In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both. CONCLUSIONS: Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.

Increasing Frequency of Interpreting Services is Associated With Shorter Peri-operative Length of Stay.

BACKGROUND: Patients with limited English proficiency have barriers to accessing care. Rather than a binary use or no use, this study uses granular data on frequency of interpreting services to determine if this frequency is associated with differences in peri-operative length of stay for patients with limited English proficiency. MATERIALS AND METHODS: This is a cross sectional study on length of stay for peri-operative admissions of at least one night during 2018, for patients who used medical interpreting services in an academic medical center in Boston, Massachusetts. The participants are split into quartiles of ascending number of interpreting events per day. The exposure for the primary outcome is the frequency of interpreting events per day during peri-operative admission. The primary study outcome measurement is peri-operative length of stay in days. RESULTS: There was a statistically significant decrease in length of stay for patients in the highest two quartiles of interpreting service frequency, compared to the lowest quartile: quartile 2 trended shorter by 1.4 d (95% CI -4.5 to 1.7, P = 0.37), quartile 3 was 4.2 d shorter (95% CI -7.6 to -0.7, P = 0.02), and quartile 4 was 4.6 d shorter (95% CI -8.1 to -1.1, P = 0.01). CONCLUSIONS: More frequent interpreting services per day during peri-operative admission are associated with shorter length of stay in adjusted analysis. The findings merit further study in an intervention to increase use of interpreting services for surgical patients with limited English proficiency to study the impact of increased frequency of culturally competent care.

Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences.

INTRODUCTION: Global health conferences are important platforms for knowledge exchange, decision-making and personal and professional growth for attendees. Neocolonial patterns in global health at large and recent opinion reports indicate that stakeholders from low- and middle-income countries (LMICs) may be under-represented at such conferences. This study aims to describe the factors that impact LMIC representation at global health conferences. METHODS: A systematic review of articles reporting factors determining global health conference attendance was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles presenting conference demographics and data on the barriers and/or facilitators to attendance were included. Articles were screened at title and abstract level by four independent reviewers. Eligible articles were read in full text, analysed and evaluated with a risk of bias assessment. RESULTS: Among 8765 articles screened, 46 articles met inclusion criteria. Thematic analysis yielded two themes: 'barriers to conference attendance' and 'facilitators to conference attendance'. In total, 112 conferences with 254 601 attendees were described, of which 4% of the conferences were hosted in low-income countries. Of the 98 302 conference attendees, for whom affiliation was disclosed, 38 167 (39%) were from LMICs. CONCLUSION: 'Conference inequity' is common in global health, with LMIC attendees under-represented at global health conferences. LMIC attendance is limited by systemic barriers including high travel costs, visa restrictions and lower acceptance rates for research presentations. This may be mitigated by relocating conferences to visa-friendly countries, providing travel scholarships and developing mentorship programmes to enable LMIC researchers to participate in global conferences.

Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery.

INTRODUCTION: C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery. METHODS: A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy. RESULTS: A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5. CONCLUSIONS: The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.