Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study.

OBJECTIVE: The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). BACKGROUND: Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. METHODS: A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. RESULTS: Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. CONCLUSIONS: We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

Investigation of heterotrophs reveals new insights in dinoflagellate evolution.

Dinoflagellates are diverse and ecologically important protists characterized by many morphological and molecular traits that set them apart from other eukaryotes. These features include, but are not limited to, massive genomes organized using bacterially-derived histone-like proteins (HLPs) and dinoflagellate viral nucleoproteins (DVNP) rather than histones, and a complex history of photobiology with many independent losses of photosynthesis, numerous cases of serial secondary and tertiary plastid gains, and the presence of horizontally acquired bacterial rhodopsins and type II RuBisCo. Elucidating how this all evolved depends on knowing the phylogenetic relationships between dinoflagellate lineages. Half of these species are heterotrophic, but existing molecular data is strongly biased toward the photosynthetic dinoflagellates due to their amenability to cultivation and prevalence in culture collections. These biases make it impossible to interpret the evolution of photosynthesis, but may also affect phylogenetic inferences that impact our understanding of character evolution. Here, we address this problem by isolating individual cells from the Salish Sea and using single cell, culture-free transcriptomics to expand molecular data for dinoflagellates to include 27 more heterotrophic taxa, resulting in a roughly balanced representation. Using these data, we performed a comprehensive search for proteins involved in chromatin packaging, plastid function, and photoactivity across all dinoflagellates. These searches reveal that 1) photosynthesis was lost at least 21 times, 2) two known types of HLP were horizontally acquired around the same time rather than sequentially as previously thought; 3) multiple rhodopsins are present across the dinoflagellates, acquired multiple times from different donors; 4) kleptoplastic species have nucleus-encoded genes for proteins targeted to their temporary plastids and they are derived from multiple lineages, and 5) warnowiids are the only heterotrophs that retain a whole photosystem, although some photosynthesis-related electron transport genes are widely retained in heterotrophs, likely as part of the iron-sulfur cluster pathway that persists in non-photosynthetic plastids.