Academic Output in Global Surgery after the Lancet Commission on Global Surgery: A Scoping Review.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) published its seminal report in 2015, carving a niche for global surgery academia. Six years after the LCoGS, a scoping review was conducted to see how the term 'global surgery' is characterized by the literature and how it relates to LCoGS and its domains. METHODS: PubMed was searched for publications between January 2015 and February 2021 that used the term 'global surgery' in the title, abstract, or key words or cited the LCoGS. Variables extracted included LCoGS domains, authorship metrics, geographic scope, and clinical specialty. RESULTS: The search captured 938 articles that qualified for data extraction. Nearly 80% of first and last authors had high-income country affiliations. Africa was the most frequently investigated region, though many countries within the region were under-represented. The World Journal of Surgery was the most frequent journal, publishing 13.9% of all articles. General surgery, pediatric surgery, and neurosurgery were the most represented specialties. Of the LCoGS domains, healthcare delivery and management were the most studied, while economics and financing were the least studied. CONCLUSION: A lack of consensus on the definition of global surgery remains. Additional research is needed in economics and financing, while obstetrics and trauma are under-represented in literature using the term 'global surgery'. Efforts in academic global surgery must give a voice to those carrying the global surgery agenda forward on the frontlines. Focusing on research capacity-building and encouraging contribution by local partners will lead to a stronger, more cohesive global surgery community.

Assessing the Rates and Reasons of Elective Surgical Cancellations on the Day of Surgery: A Multicentre Study from Urban Indian Hospitals.

BACKGROUND: Cancellations of elective surgeries on the day of surgery (DOS) can lead to added financial burden and wastage of resources for healthcare facilities; as well as social and emotional problems to patients. These cancellations act as barriers to delivering efficient surgical services. Optimal utilisation of the available resources is necessary for resource-constrained low-and-middle-income countries (LMIC). This study investigates the rate and causes of cancellations of elective surgeries on the DOS in various surgical departments across ten hospitals in India. METHODS: A research consortium 'IndSurg' led by World Health Organisation Collaboration Centre (WHOCC) for Research in Surgical Care Delivery in LMICs, India conducted this multicentre retrospective cross-sectional study to analyse the cancellations of elective/planned surgical operations on DOS across urban secondary and tertiary level hospitals. We audited surgical records of a pre-decided period of six weeks for cancellations, documented relevant demographic information and reasons for cancellations. RESULTS: We analysed records from the participating hospitals, with an overall cancellation rate of 9.7% (508/5231) on the DOS for elective surgical operations. Of these, 74% were avoidable cancellations. A majority (30%) of these 508 cancellations were attributed to insufficient resources, 28% due to patient's refusal or failure to show-up, and 22% due to change in patient's medical status. CONCLUSION: We saw a preponderance of avoidable reasons for elective surgery cancellations. A multidisciplinary approach with adequate preoperative patient counselling, timely communication between the patients and caregivers, adequate preoperative anaesthetic assessment, and planning by the surgical team may help reduce the cancellation rate.

Beyond the Ivory Tower: Perception of academic global surgery by surgeons in low- and middle-income countries.

Interest in global surgery has surged amongst academics and practitioners in high-income countries (HICs), but it is unclear how frontline surgical practitioners in low-resource environments perceive the new field or its benefit. Our objective was to assess perceptions of academic global surgery amongst surgeons in low- and middle-income countries (LMICs). We conducted a cross-sectional e-survey among surgical trainees and consultants in 62 LMICs, as defined by the World Bank in 2020. This paper is a sub-analysis highlighting the perception of academic surgery and the association between practice setting and responses using Pearson's Chi-square test. Analyses were completed using Stata15. The survey received 416 responses, including 173 consultants (41.6%), 221 residents (53.1%), 8 medical graduates (1.9%), and 14 fellows (3.4%). Of these, 72 responses (17.3%) were from low-income countries, 137 (32.9%) from lower-middle-income countries, and 207 (49.8%) from upper-middle-income countries. 286 respondents (68.8%) practiced in urban areas, 34 (8.2%) in rural areas, and 84 (20.2%) in both rural and urban areas. Only 185 (44.58%) were familiar with the term "global surgery." However, 326 (79.3%) agreed that collaborating with HIC surgeons for research is beneficial to being a global surgeon, 323 (78.8%) agreed that having an HIC co-author improves likelihood of publication in a reputable journal, 337 (81.6%) agreed that securing research funding is difficult in their country, 195 (47.3%) agreed that their institutions consider research for promotion, 252 (61.0%) agreed that they can combine research and clinical practice, and 336 (82%) are willing to train HIC medical students and residents. A majority of these LMIC surgeons noted limited academic incentives to perform research in the field. The academic global surgery community should take note and foster equitable collaborations to ensure that this critical segment of stakeholders is engaged and has fewer barriers to participation.

The Paradoxical Criticism of Gender Parity in Surgery.

The present work explores a controversy surrounding gender equity in surgical residency programs, particularly focusing on the Stanford University and University of Washington (UW) General Surgery Residency cohorts. While the Stanford cohort, which consisted mostly of women, faced criticism from nonmedical audiences claiming that gender was prioritized over qualifications, the all-male radiology residents received less attention and fewer criticisms. The article highlights the double standards and challenges the notion of meritocracy. It discusses the gender and racial disparities in surgical residency programs, emphasizing the need for diversity and inclusion. The presence of diverse female representation is seen as a valuable asset that brings compassion, teamwork, and inclusive leadership to the field. The article calls for active support from institutions, male allies, and transparency in collecting applicant demographic data to address biases and promote gender diversity in surgery.

What to scale first? A cross-sectional analysis of factors affecting cesarean delivery rates at first referral units in Bihar, India.

BACKGROUND: Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates. OBJECTIVES: We aimed to determine caesarean delivery rates at Bihar's first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates. METHODS: This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018-March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates. RESULTS: Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0-10), 39% had an anaesthetist (range 0-5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0-4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9-55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1-1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3-1.9, p < 0.001) were associated with facility-level CD rates. CONCLUSION: Only 3.1% of the institutional childbirths in Bihar's FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.

Geographic and socioeconomic inequities in cesarean delivery rates at the district level in Madhya Pradesh, India: A secondary analysis of the national family health survey-5.

BACKGROUND: In India, caesarean delivery (CD) accounts for 17% of the births, of which 41% occur in private facilities. However, areas to CD in rural areas are limited, particularly for the poor populations. Little information is available on state-wise district-level CD rates by geography and the population wealth quintiles, especially in Madhya Pradesh (MP), the fifth most populous and third poorest state. OBJECTIVE: Investigate geographic and socioeconomic inequities of CD across the 51 districts in MP and compare the contribution of public and private healthcare facilities to the overall state CD rate. METHODS: This cross-sectional study utilised the summary fact sheets of the National Family Health Survey (NFHS)-5 performed from January 2019 to April 2021. Women aged 15 to 49 years, with live births two years preceding the survey were included. District-level CD rates in MP were used to determine the inequalities in accessing CD in the poorer and poorest wealth quintiles. CD rates were stratified as <10%, 10-20% and >20% to measure equity of access. A linear regression model was used to examine the correlation between the fractions of the population in the two bottom wealth quintiles and CD rates. RESULTS: Eighteen districts had a CD rate below 10%, 32 districts were within the 10%-20% threshold and four had a rate of 20% or higher. Districts with a higher proportion of poorer population and were at a distance from the capital city Bhopal were associated with lower CD rates. However, this decline was steeper for private healthcare facilities (R2 = 0.382) revealing a possible dependency of the poor populations on public healthcare facilities (R2 = 0.009) for accessing CD. CONCLUSION: Although CD rates have increased across MP, inequities within districts and wealth quintiles exist, warranting closer attention to the outreach of government policies and the need to incentivise CDs where underuse is significant.

Breast Conservative Surgery for Breast Cancer: Indian Surgeon's Preferences and Factors Influencing Them.

Background: It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient's choice, availability and accessibility of infrastructure, and surgeon's choice. We aimed to elucidate the Indian surgeons' perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS. Methods: We conducted a survey-based cross-sectional study in January-February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS. Results: A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons 'almost always' offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p < 0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p < 0.05). Surgeons' years of practice, age, sex and hospital setting did not influence the surgery offered. Conclusion: Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01601-y.

Profile and triage validity of trauma patients triaged green: a prospective cohort study from a secondary care hospital in India.

OBJECTIVES: To evaluate the profile of non-urgent patients triaged 'green', as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS). DESIGN: Prospective cohort study. SETTING: A secondary care hospital in Mumbai, India. PARTICIPANTS: Patients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01-Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures were mortality within 24 hours, 30 days and mistriage. RESULTS: We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital. CONCLUSIONS: Our study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Do authorship disputes deter Indian medical students from pursuing research?

Medicine, being an ever-expanding field, makes it crucial for doctors-in-training to understand research and its methodology and translate this into their clinical practice. However, in India, the response of medical students and residents in adopting this has been sluggish, primarily owing to high levels of stress attributed to the extensive academic curriculum, hectic duty hours, and shortage of workforce that leads to an unacceptably high patient load [1]. Lack of funding and mentorship programmes, difficulty in data collection and analysis, and no additional credits awarded to students for the time invested act as additional barriers to taking up research projects [2]. An important but rarely discussed disincentive is the disputes regarding credits awarded to research in a publication.

The need for craniofacial trauma and oncologic reconstruction in global surgery.

The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.

Nurse and physician reflections on the application of a quality standards training program to reduce maternal mortality.

OBJECTIVE: High rates of maternal mortality persist in Low and Middle Income countries, despite increasing rates of facility-based births, suggesting a need to focus on quality of maternity care. The purpose of the current study was to evaluate provider perspectives on the implementation of material taught during an evidence-based medical education session aimed at reducing common causes of maternal death in government hospitals in India. DESIGN: Several months after the training, labor room nurses and physicians from twenty-two hospitals participated in semi-structured focus group discussions. SETTING: Training sessions were held in an off-site location in each of fourteen districts across Kerala, India. PARTICIPANTS: Nurses and physicians working in labor and delivery wards within government hospitals. INTERVENTION: Participants were trained on evidence-based practices to treat and prevent common causes of maternal death. Training was a combination of lecture and hands-on practice, conducted over a single working day in a classroom setting. MEASUREMENTS AND FINDINGS: Main items of discussion were challenges to implementing material taught in the training session and identification of successful strategies to adopt the recommended standards of care. Primary barriers to implementation of quality standards were provider unwillingness to apply new techniques, inadequate infrastructure, challenges with staffing capacity and lack of required materials and equipment. Facilitators to implementing standards of care included staff motivation, supportive leadership and co-training of nurses and doctors. KEY CONCLUSIONS: In international settings, clinical uptake of evidence-based material taught in a classroom format may differ by physician attitude and may be moderated by external factors such as infrastructure quality and equipment availability. In some circumstances, highly motivated staff may overcome external barriers through effort and persistence. IMPLICATIONS FOR PRACTICE: Continuing medical education aimed to improve utilization of evidence-based maternity care in low- and middle-income countries may have limited effect without complementary support from hospital administration and provision of adequate infrastructure, equipment and materials to support evidence-based practice.