Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance).

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

[Cutaneous surgery myths and traditions in the Emergency Department]. / Mythes et traditions des urgences chirurgicales cutanées.

Traditions and myths die hard in many fields of medicine but especially in the field of cutaneous surgical emergencies. In a few selected paragraphs, we set out to undo some of these myths with the aim of a less ritualized approach to daily gestures.

Les traditions, agrémentées de mythes, ont la vie dure dans de nombreux domaines de la médecine, mais en particulier dans le domaine des urgences chirurgicales cutanées. Par quelques chapitres choisis, nous nous attelons à briser quelques mythes dans le sens d'une approche moins ritualisée de gestes quotidiens dans nos services d'urgences et dans les cabinets médicaux et policliniques.

Essential surgery: the way forward.

INTRODUCTION: Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need. METHODS: Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability. RESULTS: Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care. CONCLUSION: A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing "Essential Surgery" is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

Impact of surgical resection for subdiaphragmatic paragangliomas.

BACKGROUND: Subdiaphragmatic paraganglioma is a rare neuroendocrine tumor for which scarce data exist regarding long-term patient outcome following resection. The aim of this study was to determine the association of surgical resection with survival. METHODS: A retrospective study at a tertiary care center was performed. Demographics, genetics, histology, and operative details were reviewed. Patients were grouped according to margin status (R0, R1, or R2) and survival calculated. RESULTS: A total of 50 patients with subdiaphragmatic paragangliomas underwent primary resection from 1999 to 2012. Median age at operation was 46 years, with a median tumor size of 6.0 cm. Of these patients, 30 (60 %) had a R0 resection, 11 (22 %) had a R1 resection, and 9 (18 %) had a R2 resection. There was no operative mortality, and 17 (34 %) patients had metastatic disease. Six (12 %) patients died, four (8 %) of whom had metastatic disease. Univariate analysis identified that age >50 years (p = 0.02) and undergoing a R2 resection (p = 0.03) were associated with a shorter overall survival (OS). Those with metastases at some point after their initial diagnosis had a shorter disease-free survival (DFS) than those without metastases (p = 0.04). Of 27 patients tested, 12 (44 %) had a germline succinyl dehydrogenase B (SDHB) mutation. SDHB immunohistochemistry identified 18 patients (of 27 who underwent staining) who had loss of SDHB expression in which 7 of 11 patients (63 %) who underwent genetic testing had a genetic mutation. CONCLUSIONS: Surgical resection of subdiaphragmatic paraganglioma is safe. Survival was longest in patients who were younger, with no metastases, or had a R0 or R1 resection. Patients who test negative for a germline mutation should undergo SDHB immunostaining to identify potential hereditary carriers missed by current genetic testing.

Value innovation: an important aspect of global surgical care.

INTRODUCTION: Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these successful innovations and their origins that have had an important impact in healthcare delivery worldwide. REVIEW: Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax. CONCLUSION: Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.

An in vitro platform for quantifying cell cycle phase lengths in primary human intestinal epithelial cells.

The intestinal epithelium dynamically controls cell cycle, yet no experimental platform exists for directly analyzing cell cycle phases in non-immortalized human intestinal epithelial cells (IECs). Here, we present two reporters and a complete platform for analyzing cell cycle phases in live primary human IECs. We interrogate the transcriptional identity of IECs grown on soft collagen, develop two fluorescent cell cycle reporter IEC lines, design and 3D print a collagen press to make chamber slides for optimal imaging while supporting primary human IEC growth, live image cell cycle dynamics, then assemble a computational pipeline building upon free-to-use programs for semi-automated analysis of cell cycle phases. The PIP-FUCCI construct allows for assigning cell cycle phase from a single image of living cells, and our PIP-H2A construct allows for semi-automated direct quantification of cell cycle phase lengths using our publicly available computational pipeline. Treating PIP-FUCCI IECs with oligomycin demonstrates that inhibiting mitochondrial respiration lengthens G1 phase, and PIP-H2A cells allow us to measure that oligomycin differentially lengthens S and G2/M phases across heterogeneous IECs. These platforms provide opportunities for future studies on pharmaceutical effects on the intestinal epithelium, cell cycle regulation, and more.

An in vitro platform for quantifying cell cycle phase lengths in primary human intestinal stem cells.

Background and Aims: The intestinal epithelium exhibits dynamic control of cell cycle phase lengths, yet no experimental platform exists for directly analyzing cell cycle phases in living human intestinal stem cells (ISCs). Here, we develop primary human ISC lines with two different reporter constructs to provide fluorescent readouts to analyze cell cycle phases in cycling ISCs. Methods: 3D printing was used to construct a collagen press for making chamber slides that support primary human ISC growth and maintenance within the working distance of a confocal microscope objective. The PIP-FUCCI fluorescent cell cycle reporter and a variant with H2A-mScarlet that allows for automated tracking of cell cycle phases (PIP-H2A) were used in human ISCs along with live imaging and EdU pulsing. An analysis pipeline combining free-to-use programs and publicly available code was compiled to analyze live imaging results. Results: Chamber slides with soft collagen pressed to a thickness of 0.3 mm concurrently support ISC cycling and confocal imaging. PIP-FUCCI ISCs were found to be optimal for snapshot analysis wherein all nuclei are assigned to a cell cycle phase from a single image. PIP-H2A ISCs were better suited for live imaging since constant nuclear signal allowed for more automated analysis. CellPose2 and TrackMate were used together to track cycling cells. Conclusions: We present two complete platforms for analyzing cell cycle phases in living primary human ISCs. The PIP-FUCCI construct allows for cell cycle phase assignment from one image of living cells, the PIP-H2A construct allows for semi-automated direct quantification of cell cycle phase lengths in human ISCs using our computational pipeline. These platforms hold great promise for future studies on how pharmaceutical agents affect the intestinal epithelium, how cell cycle is regulated in human ISCs, and more.

Meta-analysis of diagnostic test accuracy in neurosurgical practice.

Comparative effectiveness research (CER) allows evidence to be evaluated on the effectiveness, benefits, and detriments of management options, diagnostic tests, or ways to deliver health care. This process can be achieved in different ways, such as with well-designed randomized controlled trials or by meta-analyses. Several medical subspecialties are increasingly using CER, but CER remains underused by the neurosurgical community. Meta-analysis is a highly accurate method that permits results from multiple well-designed research studies to be quantitatively compared. Meta-analysis can be performed in many settings, such as the evaluation of treatment or of a diagnostic test or prognostic factor. Meta-analyses of randomized controlled treatment trials are well known, but there is a paucity of papers describing the ways to perform a meta-analysis of a diagnostic test. The aim of this paper is to improve neurosurgeons' familiarity with the meta-analysis of diagnostic test accuracy by describing and detailing each stage leading to publication.

Return-to-Sport Time and Postoperative Performance in MLB Players Undergoing Wrist Arthroscopy.

BACKGROUND: Wrist injuries are common in sports and can result in prolonged time missed from playing. This study aimed to determine in Major League Baseball-players after arthroscopic wrist surgery the return-to-sport (RTS) rate, postoperative career length, and changes in performance compared with preoperative statistics and matched controls. METHODS: Major League Baseball players who underwent arthroscopic wrist surgery from 1990 to 2019 were identified. Demographic and performance data were collected for each player, and matched controls were identified. Comparisons were made via paired samples Student t tests. RESULTS: Twenty-six players (27 surgeries) were identified. The average age of included players was 28.9 ± 2.9 years with an average professional experience of 5.2 ± 3.4 years. Eighty-four percent of players returned to sport, with an average RTS time of 5.0 ± 2.7 months. A statistically significant (P < .05) decrease was seen in preoperative and postoperative runs scored per season (95.6 ± 91.3 vs 41.0 ± 29.5), batting average (BA) (0.270 ± 0.024 vs 0.240 ± 0.036), and average wins above replacement (WAR) (1.5 ± 1.1 vs 0.8 ± 0.9). CONCLUSION: Major League Baseball players who underwent arthroscopic wrist surgery had an RTS rate of 84% at a mean time of 5.0 months. There was no significant difference in performance statistics between cases postoperatively and matched controls overall, with some differences in performance found when categorized by position. However, a significant decrease in performance among case players was observed between preoperative and postoperative performance, including runs per season, BA, and WAR.

Percutaneous Needle Fasciotomy versus Collagenase Injection for Dupuytren's Contracture: A Systematic Review of Comparative Studies.

Introduction The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren's contracture. Materials and Methods A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren's contracture. Results Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates. Conclusion For the treatment of Dupuytren's contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.

Performance and Return to Sport After Open Fracture in National Football League Players.

BACKGROUND: Open fractures are debilitating injuries for athletes. No prior studies have investigated open fractures in National Football League (NFL) players. PURPOSE: To compare outcomes after open fracture in NFL players in terms of (1) time to return to sport (RTS), (2) postinjury career length and games played per season, (3) postinjury performance, and (4) postinjury performance compared with matched controls. STUDY DESIGN: Retrospective comparative series; Level of evidence, 3. METHODS: Publicly available records were used to identify NFL players who had sustained an open fracture between 1970 and 2018. Controls were matched to injured players by age, experience, position, and preinjury performance. RTS was defined as playing in at least 1 NFL game after open fracture. Comparisons between injured and control players were made using the paired-samples Student t test. RESULTS: Injuries in 37 players were analyzed (age, 27.2 ± 3.6 years; experience, 4.4 ± 3.6 seasons).  The 3 most common locations for open fracture were the tibia/fibula (n = 16), hand/finger (n = 12), and forearm/wrist (n = 3). A total of 30 (81%) players had a mean time of RTS of 9.3 ± 8.2 months after open fracture; of these players, 4 (13.3%) who sustained hand/finger open fracture did not undergo surgical treatment. There was no difference in postinjury career length or games played per season between control and injured players. Postinjury performance was similar to preinjury performance in injured players, and postinjury performance scores were similar between injured and control players. There were significant differences between players who sustained upper extremity and lower extremity open fractures in RTS time (4.0 ± 4.8 vs 14.6 ± 7.4 months, respectively; P = .00007) and postinjury performance (6.4 ± 4.3 vs 3.3 ± 2.1, respectively; P = .03). CONCLUSION: RTS after open fracture among NFL players was high. Players who sustained an open fracture had similar games played per season, career length, and performance compared with matched controls. Players who sustained an upper extremity open fracture had a faster RTS time, higher RTS rate, and improved postinjury performance compared with players who sustained a lower extremity open fracture.

Retrospective Analysis of Geriatric Major Trauma Patients Admitted in the Shock Room of a Swiss Academic Hospital: Characteristics and Prognosis.

Increased life expectancy exposes a great number of elderly people to serious accidents, thus increasing the amount of major geriatric trauma cases. The aim of our study was to determine the profile of elderly patients undergoing major trauma, and the contributing factors predicting mortality in this specific patient group, compared to the younger population. Retrospective analysis of 1051 patients with major trauma admitted over ten years in a Level-1 trauma center was performed. Data collected were: history, nature and type of trauma; age and sex; vital signs on admission; injury severity score; shock index; comorbidities; coagulation diathesis; injury patterns; emergency measures taken; main diagnosis; mortality; and length of hospital and intensive care unit (ICU) stay. Geriatric patients admitted for major trauma have a mortality rate almost four times greater (47%) than their younger counterparts (14%) with the same ISS. According to statistical regression analysis, anti-platelet therapy (OR 3.21), NACA (National Advisory Committee for Aeronautics) score (OR 2.23), GCS (OR 0.83), ISS (OR 1.07) and age (OR 1.06) are the main factors predicting mortality. Conclusion: Geriatric major trauma patients admitted to our trauma resuscitation area have a high mortality rate. Age, GCS, ISS and NACA scores as well as anti-platelet therapy are the main factors predicting mortality.

Preoperative Warming Reduces Intraoperative Hypothermia in Total Joint Arthroplasty Patients.

INTRODUCTION: Perioperative hypothermia (PH) is common in patients undergoing total joint arthroplasty (TJA). A previous study at our institution identified the largest drop in core body temperature between preoperative holding and induction of anesthesia. This study evaluates the effect of preoperative warming measures on PH in TJA patients. METHODS: A retrospective review was conducted of 672 patients undergoing TJA at our institution between April 1 and October 31, 2017. Under the new normothermia protocol, patients received warmed intravenous fluids and forced-air warming gowns in the preoperative holding area. Time and temperature data for the perioperative period were collected from the electronic health record. Chi-square and paired t-tests were used to compare between total knee arthroplasty and total hip arthroplasty patients and between new and old protocols. RESULTS: In the new protocol, 173 of 672 (26%) patients were hypothermic at incision compared with 140 of 383 (37%) patients in the previous protocol (P < 0.05). The largest drop in core body temperature occurred between preoperative holding and induction of anesthesia. The duration of time from operating room entry to incision was less for normothermic than for hypothermic patients. The duration of hypothermia was similar between new and old protocols overall, but markedly fewer total hip arthroplasty patients remained hypothermic for the entire surgery under the new protocol. CONCLUSION: Adding forced-air warming preoperatively to our warming protocol reduced the rate of PH by approximately 30%. The time from entry into the operating room to the start of surgery should be minimized because patients are vulnerable to PH during this interval.

Human papilloma virus type and recurrence rate after surgical clearance of anal condylomata acuminata.

BACKGROUND: Anal condylomata acuminata (ACA) are caused by human papilloma virus (HPV) infection which is transmitted by close physical and sexual contact. The result of surgical treatment of ACA has an overall success rate of 71% to 93%, with a recurrence rate between 4% and 29%. The aim of this study was to assess a possible association between HPV type and ACA recurrence after surgical treatment. METHODS: We performed a retrospective analysis of 140 consecutive patients who underwent surgery for ACA from January 1990 to December 2005 at our tertiary University Hospital. We confirmed ACA by histopathological analysis and determined the HPV typing using the polymerase chain reaction. Patients gave consent for HPV testing and completed a questionnaire. We looked at the association of ACA, HPV typing, and HIV disease. We used chi, the Monte Carlo simulation, and Wilcoxon tests for statistical analysis. RESULTS: Among the 140 patients (123 M/17 F), HPV 6 and 11 were the most frequently encountered viruses (51% and 28%, respectively). Recurrence occurred in 35 (25%) patients. HPV 11 was present in 19 (41%) of these recurrences, which is statistically significant, when compared with other HPVs. There was no significant difference between recurrence rates in the 33 (24%) HIV-positive and the HIV-negative patients. CONCLUSIONS: HPV 11 is associated with higher recurrence rate of ACA. This makes routine clinical HPV typing questionable. Follow-up is required to identify recurrence and to treat it early, especially if HPV 11 has been identified.