Value of Global Surgical Activities for US Academic Health Centers: A Position Paper by the Association for Academic Surgery Global Affairs Committee, Society of University Surgeons Committee on Global Academic Surgery, and American College of Surgeons' Operation Giving Back.

BACKGROUND: Academic global surgery value to low- and middle-income countries (LMICs) is increasingly understood, yet value to academic health centers (AHCs) remains unclear. STUDY DESIGN: A task force from the Association for Academic Surgery Global Affairs Committee and the Society for University Surgeons Committee on Global Academic Surgery designed and disseminated a survey to active US academic global surgeons. Questions included participant characteristics, global surgeon qualifications, trainee interactions, academic output, productivity challenges, and career models. The task force used the survey results to create a position paper outlining the value of academic global surgeons to AHCs. RESULTS: The survey had a 58% (n = 36) response rate. An academic global surgeon has a US medical school appointment, spends dedicated time in an LMIC, spends vacation time doing mission work, or works primarily in an LMIC. Most spend 1 to 3 months abroad annually, dedicating <25% effort to global surgery, including systems building, teaching, research, and clinical care. Most are university-employed and 65% report compensation is equivalent or greater than colleagues. Academic support includes administrative, protected time, funding. Most institutions do not use specific global surgery metrics to measure productivity. Barriers include funding, clinical responsibilities, and salary support. CONCLUSIONS: Academic global surgeons spend a modest amount of time abroad, require minimal financial support, and represent a low-cost investment in an under-recognized scholarship area. This position paper suggests measures of global surgery that could provide opportunities for AHCs and surgical departments to expand missions of service, education, and research and enhance institutional reputation while achieving societal impact.

Public Health Policy and Experience of the 2009 H1N1 Influenza Pandemic in Pune, India.

BACKGROUND: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. METHODS: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. RESULTS: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. CONCLUSION: The World Health Organization's (WHO's) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies.

Metastatic Malignant Thymoma to the Abdomen: A SEER Database Review and Assessment of Treatment Strategies.

BACKGROUND: Thymoma is a neoplasm occurring in 0.15 of 100,000 persons/year. Abdominal metastases are rare. We report the incidence of malignant thymoma (MT) and suggest imaging and treatment options for cases of abdominal metastasis. METHODS: A National Cancer Institute's Surveillance, Epidemiology and End Results database review was conducted to identify MT cases, followed by a literature review examining cases of metastases to the abdomen. Incidence rates were calculated, and symptoms, treatments, size and location of tumors, disease-free interval (DFI), and survival time were recorded. RESULTS: From 1973 to 2008, a total of 1,588 MT cases were identified (45.4 cases/year), which were extrapolated to 2,724 over 60 years. Incidence has risen from 17 cases in 1973 to 90 cases in 2008, with a larger incidence in males than females (0.23 vs. 0.17 per 100,000). There were 25 cases of abdominal metastasis (0.92%), 13 of which were asymptomatic. There was a wide variety of DFI and survival noted amongst the case reports. Multiple treatment modalities were used. CONCLUSIONS: The incidence of MT is on the rise with a male predominance. All patients should receive routine imaging to look for extrathoracic metastases as half will not have symptoms. All patients with abdominal metastases should be treated using a multimodal approach.

POSSUM accurately predicts morbidity for pancreatic resection.

BACKGROUND: The Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) is a predictive scoring system for postoperative morbidity. While numerous studies validate its application to major abdominal surgery, few exclusively consider pancreatic resections, whose unique complications are costly and problematic. We examined whether POSSUM could accurately reflect clinical and economic outcomes in pancreatic resection. METHODS: 326 consecutive pancreatic resections (227 pancreaticoduodenectomies, 87 distal, 7 central, and 5 total pancreatectomies) were performed between October 2001 and January 2007. POSSUM score was prospectively calculated for each case, and patients were stratified to quintiles of morbidity risk: < or = 20%, 20-40%, 40-60%, 60-80%, > or = 80%. Actual clinical and economic outcomes were compared across the groups. Predictive risk assessment was further evaluated independently within each resection type. Logistic regression analysis was performed to identify specific POSSUM parameters predictive of postoperative morbidity. RESULTS: Observed and Expected morbidity rates were equivalent (53.1% vs 55.5%) with an overall O/E ratio of 0.96. Although no patients presented with POSSUM scores below 20%, a relatively equal distribution was assigned to the remaining risk cohorts. Clinical and economic outcomes progressively worsened with escalations in POSSUM scores. Increasing morbidity risk was associated with significantly longer hospital stays, higher rates of complications, and more blood transfusions, ICU management, and discharge to rehabilitation facilities. This had considerable economic impact, as mean hospital costs rose from $19,951 in the 20-40% risk cohort, to $31,281 in the > or = 80% group. Breakdown by operation type demonstrates that POSSUM definitively predicts morbidity following both proximal and distal resection, but more accurately forecasts the need for ICU management and rehabilitation placement when pancreatoduodenectomy is performed. Multivariate analysis revealed that one-half of POSSUM parameters were significant contributors for postoperative morbidity, with age, preoperative hemoglobin concentration, and intraoperative blood loss demonstrating the strongest correlations. CONCLUSION: POSSUM is a valuable perioperative scoring system for evaluating variance in pancreatic surgical methods and outcomes, and can be employed to guide management decisions that impact postoperative recovery.