Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda.

BACKGROUND: An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience. METHODS: An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys. RESULTS: Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast. CONCLUSIONS: The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

Shotgun Wounds: Nationwide Trends in Epidemiology, Injury Patterns, and Outcomes from US Trauma Centers.

BACKGROUND: Shotguns represent a distinct form of ballistic injury because of projectile scatter and variable penetration. Due in part to their rarity, existing literature on shotgun injuries is scarce. OBJECTIVE: This study defined the epidemiology, injury patterns, and outcomes after shotgun wounds at a national level. METHODS: Patients with shotgun injury were identified from the National Trauma Data Bank (2007-2014). Transferred patients and those with missing procedure data were excluded. Demographics, injury data, and outcomes were collected and analyzed. Categorical variables are presented as number (percentage) and continuous variables as median (interquartile range). RESULTS: Shotgun wounds comprised 9% of all firearm injuries. After exclusions, 11,292 patients with shotgun injury were included. The median age was 29 years (21-43) and most were male (n = 9887, 88%). Most injuries occurred in the South (n = 4092, 36%) and among white patients (n = 4945, 44%). The median Injury Severity Score was 9 (3-16). Overall in-hospital mortality was 14% (n = 1341), with 669 patients (7%) dying in the emergency department. Assault was the most common injury intent (n = 6762, 60%), followed by accidental (n = 2081, 19%) and self-inflicted (n = 1954, 17%). The lower and upper extremities were the most commonly affected body regions (n = 4071, 36% and n = 3422, 30%, respectively), while the head was the most severely injured (median Abbreviated Injury Scale score 4 [2-5]). CONCLUSIONS: In the United States, shotgun wounds are an infrequent mechanism of injury. Shotgun wounds as a result of interpersonal violence far outweigh self-inflicted and accidental injuries. White men in their 20s in the southern parts of the country are most commonly affected and thereby delineate the high-risk patient population for injury by this mechanism at a national level.

Data Improvement Through Simplification: Implications for Low-Resource Settings.

BACKGROUND: The focus of many data collection efforts centers on creation of more granular data. The assumption is that more complex data are better able to predict outcomes. We hypothesized that data are often needlessly complex. We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) scoring system. METHODS: First, we created every possible consecutive two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA. We compared the predictive ability of these simplified scores for postoperative outcomes for 2.3 million patients in the NSQIP database. Individual model performance was assessed by comparing receiver operator characteristic (ROC) curves for each model with the standard ASA. RESULTS: Two of our 4-category models and one of our 3-category models had ability to predict all outcomes equivalent to standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the three best performing simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and when included in a multivariate model. CONCLUSIONS: It is assumed that the most granular data and use of the largest number of variables for risk-adjusted predictions will increase accuracy. This complexity is often at the expense of utility. Using the single best predictor in surgical outcomes research, we have shown this is not the case. In this example, we demonstrate that one can simplify ASA into a 3-category variable without losing any ability to predict outcomes.

Derivation, Validation and Application of a Pragmatic Risk Prediction Index for Benchmarking of Surgical Outcomes.

BACKGROUND: Despite the existence of multiple validated risk assessment and quality benchmarking tools in surgery, their utility outside of high-income countries is limited. We sought to derive, validate and apply a scoring system that is both (1) feasible, and (2) reliably predicts mortality in a middle-income country (MIC) context. METHODS: A 5-step methodology was used: (1) development of a de novo surgical outcomes database modeled around the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) in South Africa (SA dataset), (2) use of the resultant data to identify all predictors of in-hospital death with more than 90% capture indicating feasibility of collection, (3) use these predictors to derive and validate an integer-based score that reliably predicts in-hospital death in the 2012 ACS-NSQIP, (4) apply the score in the original SA dataset and demonstrate its performance, (5) identify threshold cutoffs of the score to prompt action and drive quality improvement. RESULTS: Following step one-three above, the 13 point Codman's score was derived and validated on 211,737 and 109,079 patients, respectively, and includes: age 65 (1), partially or completely dependent functional status (1), preoperative transfusions ≥4 units (1), emergency operation (2), sepsis or septic shock (2) American Society of Anesthesia score ≥3 (3) and operative procedure (1-3). Application of the score to 373 patients in the SA dataset showed good discrimination and calibration to predict an in-hospital death. A Codman Score of 8 is an optimal cutoff point for defining expected and unexpected deaths. CONCLUSION: We have designed a novel risk prediction score specific for a MIC context. The Codman Score can prove useful for both (1) preoperative decision-making and (2) benchmarking the quality of surgical care in MIC's.

Validation of an Electronic Surgical Outcomes Database at Mbarara Regional Referral Hospital, Uganda.

BACKGROUND: Accurate, complete and sustainable methods of tracking patients and outcomes in low-resource settings are imperative as we launch efforts to improve surgical care globally. The Surgical services QUality Assessment Database (SQUAD) at the Mbarara Regional Referral Hospital in Uganda is one of very few electronic surgical databases in a low-resource setting. We evaluated the completeness and accuracy of SQUAD. METHODS: Data were prospectively collected on 20 of the most clinically relevant variables captured by SQUAD for all general surgery patients admitted to MRRH over a two-week period. Patients were followed until discharge, death or hospital day 30; whichever occurred first. These data were compared to that in SQUAD for the same time period for completeness and accuracy. RESULTS: Of 186 unique patients seen over the two-week period, 172 (92.5%) were captured by SQUAD. The capture rate was greater than 86% for each of the 20 variables evaluated, except American Society of Anesthesiologists score, which had a 69% capture rate. Regarding accuracy, there was almost perfect agreement for 16/20 variables (all k > 0.81), substantial agreement for 2/20 variables (k 0.63, 0.73) and moderate agreement for the remaining 2/20 variables (k 0.43, 0.48) between SQUAD and the prospectively collected data. CONCLUSION: SQUAD is an electronic surgical database that has been implemented and sustained in a low-resource setting. For the 20 variables evaluated, the data within SQUAD are highly complete and accurate. This database may serve as a model for the development of additional surgical databases in low-resource environments.

Access to Safe, Timely, and Affordable Surgical Care in Uganda: A Stratified Randomized Evaluation of Nationwide Public Sector Surgical Capacity and Core Surgical Indicators.

BACKGROUND: Access to safe surgery is critical to health, welfare, and economic development. In 2015, the Lancet Commission on Global Surgery recommended that all countries collect surgical indicators to lend insight into improving surgical care. No nationwide high-quality data exist for these metrics in Uganda. METHODS: A standardized quantitative hospital assessment and a semi-structured interview were administered to key stakeholders at 17 randomly selected public hospitals. Hospital walk-throughs and retrospective reviews of operative logbooks were completed. RESULTS: This study captured information for public hospitals serving 64.0% of Uganda's population. On average, <25% of the population had 2 h access to a surgically capable facility. Hospitals averaged 257 beds/facilities and there were 0.2 operating rooms per 100,000 people. Annual surgical volume was 144.5 cases per 100,000 people per year. Surgical, anesthetic, and obstetrician physician workforce density was 0.3 per 100,000 people. Most hospitals reported having electricity, oxygen, and blood available more than half the time and running water available at least three quarters of the time. In total, 93.8% of facilities never had access to a CT scan. Sterile gloves, nasogastric tubes, and Foley catheters were frequently unavailable. Uniform outcome reporting does not exist, and the WHO safe surgery checklist is not utilized. CONCLUSION: The Ugandan public hospital system does not meet LCoGS targets for surgical access, workforce, or surgical volume. Critical policy and programmatic developments are essential to build surgical capacity and facilitate provision of safe, timely, and affordable surgical care. Surgery must become a public health priority in Uganda and other low resource settings.

Quantifying Pediatric Gun Violence by Location, Time of Day, and Day of Week.

BACKGROUND: Firearm injuries are the leading cause of pediatric deaths. The objective of this study was to describe the location and timing of pediatric firearm injuries and to determine the proportion of these injuries that occur within schools in the United States. METHODS: In this retrospective cohort study, we used national emergency medical services (EMS) data from 2019 to evaluate dispatches to firearm injuries involving school-aged children (age 5-18). We extracted incident location type, patient demographics, number of patients on scene, and injury intent. RESULTS: We identified 4764 EMS dispatches for firearm injuries in school-aged children during 2019. Assault was the most common cause of injury (53.9 %), followed by unintentional shootings (12.1 %) and self-inflicted injuries (6.1 %). Most incidents involved a single patient (91.4 %). Private residence (51.5 %) was the most common location, followed by street/road (23.8 %). 81 firearm injuries (1.7 %) occurred in a school. Private residence was the most common location of injury across all injury intents. During school hours, most firearm injuries occurred in a private residence (51.6 %) or on a street/road (19.9 %). A total of 63 dispatches (1.3 %) were considered a mass casualty incident, of which 9 (14 %) occurred in a school. CONCLUSIONS: Regardless of injury intent or time of day, the most common location for pediatric firearm injuries was a private home. Firearm injuries within schools were far less frequent. In designing prevention strategies, our data calls for renewed focus on preventing children from accessing firearms in the home and instituting comprehensive, community-based after school programs. TYPE OF STUDY: Retrospective cohort. LEVEL OF EVIDENCE: III.

The Global Macroeconomic Burden of Burn Injuries.

BACKGROUND: Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution. METHODS: Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach. RESULTS: There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs) of Oceania (0.24%; 95% UI, 0.09% to 0.42%) and Eastern Europe (0.24%; 95% UI, 0.19% to 0.30%) compared with high-income country regions such as Western Europe (0.06%; 95% UI, 0.04% to 0.09%). Mortality-incidence ratios were highest in LMIC regions, highlighting a lack of treatment access, with southern sub-Saharan Africa reporting a mortality-incidence ratio of 40.1 per 1000 people compared with 1.9 for Australasia. CONCLUSIONS: Burden of disease and resulting economic losses because of burn injuries are substantial worldwide and are disproportionately higher in LMICs. Possible effective solutions include targeted education, advocacy, and legislation to decrease incidence and investing in existing burn centers to improve treatment access.

Multicenter evaluation of financial toxicity and long-term health outcomes after injury.

BACKGROUND: Despite the growing awareness of the negative financial impact of traumatic injury on patients' lives, the association between financial toxicity and long-term health-related quality of life (hrQoL) among trauma survivors remains poorly understood. METHODS: Patients from nine trauma centers participating in a statewide trauma quality collaborative had responses from longitudinal survey data linked to inpatient trauma registry data. Financial toxicity was defined based on patient-reported survey responses regarding medical debt, work or income loss, nonmedical financial strain, and forgone care due to costs. A financial toxicity score ranging from 0 to 4 was calculated. Health-related quality of life was assessed using the EuroQol 5 Domain tool. Multivariable regression models evaluated the association between financial toxicity and hrQoL outcomes while adjusting for patient demographics, injury severity and inpatient treatment intensity, and health systems variables. RESULTS: Among the 403 patients providing 510 completed surveys, rates of individual financial toxicity elements ranged from 21% to 46%, with 65% of patients experiencing at least one element of financial toxicity. Patients with any financial toxicity had worse summary measures of hrQoL and higher rates of problems in all five EuroQol 5 Domain domains ( p < 0.05 for all). Younger age, lower household income, lack of insurance, more comorbidities, discharge to a facility, and air ambulance transportation were independently associated with higher odds of financial toxicity ( p < 0.05 for all). Injury traits and inpatient treatment intensity were not independently associated with financial toxicity. CONCLUSION: A majority of trauma survivors in this study experienced some level of financial toxicity, which was independently associated with worse risk-adjusted health outcomes across all hrQoL measures. Risk factors for financial toxicity are not related to injury severity or treatment intensity but rather to sociodemographic variables and measures of prehospital and posthospital health care resource utilization. Targeted interventions and policies are needed to address financial toxicity and ensure optimal recovery for trauma survivors. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Understanding and Assisting the Recovery of Non-English-Speaking Trauma Survivors: Assessment of the NESTS Pathway.

INTRODUCTION: Spanish-speaking trauma and burn patients have unique needs in their post-discharge care navigation. The confluence of limited English proficiency, injury recovery, mental health, socioeconomic disadvantages, and acute stressors following hospital admission converge to enhance patients' vulnerability, but their specific needs and means of meeting these needs have not been well described. METHODS: This prospective, cross-sectional survey study describes the results of a multi-institutional initiative devised to help Spanish-speaking trauma and burn patients in their care navigation after hospitalization. The pathway consisted of informational resources, intake and follow up surveys, and multiple points of contact with a community health worker who aids in accessing community resources and navigating the healthcare system. RESULTS: From January 2022-November 2023, there were 114 patients identified as eligible for the NESTS pathway. Of these, 80 (70.2%) were reachable and consented to participate, and 68 of these patients were approached in person during their initial hospitalization. After initial screening, 60 (75.0%) of the eligible patients had a mental health, social services, or other need identified via our survey instrument. During the initial consultation with the CHW, 48 of the 60 patients with any identified need were connected to a resource (80%). Food support was the most prevalent need (N=46, 57.5%). More patients were connected to mental health resources (N=16) than reported need in this domain (N=7). CONCLUSIONS: The NESTS pathway identified the specific needs of Spanish-speaking trauma and burn patients in their recovery, notably food, transportation, and utilities. The pathway also addressed disparities in post-discharge care by connecting patients with community resources, with particular improvement in access to mental healthcare.

The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors.

BACKGROUND: Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes. METHODS: Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated. RESULTS: Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores. CONCLUSION: Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Surgical capacity is disaster preparedness: A scoping review of how surgery and anesthesiology departments responded to COVID-19.

OBJECTIVE: This study evaluated how surgical and anesthesiology departments adapted their resources in response to the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: This scoping review used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol, with Covidence as a screening tool. An initial search of PubMed, Embase, Web of Science, Global Index Medicus, and Cochrane Systematic Reviews returned 6,131 results in October 2021. After exclusion of duplicates and abstract screening, 415 articles were included. After full-text screening, 108 articles remained. RESULTS: Most commonly, studies were retrospective in nature (47.22 percent), with data from a single institution (60.19 percent). Nearly all studies occurred in high-income countries (HICs), 78.70 percent, with no articles from low-income countries. The reported responses to the COVID-19 pandemic involving surgical departments were grouped into seven categories, with multiple responses reported in some articles for a total of 192 responses. The most frequently reported responses were changes to surgical department staffing (29.17 percent) and task-shifting or task-sharing of personnel (25.52 percent). CONCLUSION: Our review reflects the mechanisms by which hospital surgical systems responded to the initial stress of the COVID-19 pandemic and reinforced the many changes to hospital policy that occurred in the pandemic. Healthcare systems with robust surgical systems were better able to cope with the initial stress of the COVID-19 pandemic. The well-resourced health systems of HICs reported rapid and dynamic changes by providers to assist in and ultimately improve the care of patients during the pandemic. Surgical system strengthening will allow health systems to be more resilient and prepared for the next disaster.

Beyond surviving: A scoping review of collaborative care models to inform the future of post-discharge trauma care.

ABSTRACT: Trauma centers demonstrate an impressive ability to save lives, as reflected by inpatient survival rates of over 95% in the United States. Nevertheless, we fail to allocate sufficient effort and resources to ensure that survivors and their families receive the necessary care and support after leaving the trauma center. The objective of this scoping review is to systematically map the research on collaborative care models (CCM) that have been put forward to improve trauma survivorship. Of 833 articles screened, we included 16 studies evaluating eight collaborative care programs, predominantly in the U.S. The majority of the programs offered care coordination and averaged 9-months in duration. Three-fourths of the programs incorporated a mental health provider within their primary team. Observed outcomes were diverse: some models showed increased engagement (e.g., Center for Trauma Survivorship, trauma quality-of-life follow-up clinic), while others presented mixed mental health outcomes and varied results on pain and healthcare utilization. The findings of this study indicate that collaborative interventions may be effective in mental health screening, PTSD and depression management, effective referrals, and improving patient satisfaction with care. A consensus on core elements and cost-effectiveness of CCMs is necessary to set the standard for comprehensive care in post-trauma recovery.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors.

INTRODUCTION: Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury. METHODS: Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission â€‹≥ â€‹3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors. RESULTS: 2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR â€‹= â€‹1.57; 95% CI â€‹= â€‹1.21, 2.03), and worse SF-12 mental (mean Δ â€‹= â€‹-1.43; 95% CI â€‹= â€‹-2.79, -0.09) and physical scores (mean Δ â€‹= â€‹-2.61; 95% CI â€‹= â€‹-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group. CONCLUSIONS: Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

Developing a Surgical Simulation Curriculum for the Rwandan Context.

OBJECTIVE: We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda. DESIGN: This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students. SETTING: University of Global Health Equity, a new medical school located in Butaro, Rwanda. PARTICIPANTS: Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship. RESULTS: The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options. CONCLUSIONS: Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis.

Background: Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors. Methods: By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach. Findings: We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model. Interpretation: Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico. Funding: None.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference.

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

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.].