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OBJECTIVE: To determine the association between SAO workforce and mortality from emergent surgical and obstetric conditions within US HR Rs. BACKGROUND: SAO workforce per capita has been identified as a core metric of surgical capacity by the Lancet Commission on Global Surgery, but its utility has not been assessed at the subnational level for a high-income country. METHODS: The number of practicing surgeons, anesthesiologists, and obstetricians per capita was estimated for all HRRs using the US Health Resources & Services Administration Area Health Resource File Database. Deaths due to emergent general surgical and obstetric conditions were determined from the Center for Disease Control and Prevention WONDER database. We utilized B-spline quantile regression to model the relationship between SAO workforce and emergent surgical mortality at different quantiles of mortality and calculated the expected change in mortality associated with increases in SAO workforce. RESULTS: The median SAO workforce across all HRRs was 74.2 per 100,000 population (interquartile range 33.3-241.0). All HRRs met the Lancet Commission on Global Surgery lower target of 20 SAO per 100,000, and 97.7% met the upper target of 40 per 100,000. Nearly 2.8 million Americans lived in HRRs with fewer than 40 SAO per 100,000. Increases in SAO workforce were associated with decreases in surgical mortality in HRRs with high mortality, with minimal additional decreases in mortality above 60 to 80 SAO per 100,000. CONCLUSIONS: Increasing SAO workforce capacity may reduce emergent surgical and obstetric mortality in regions with high surgical mortality but diminishing returns may be seen above 60 to 80 SAO per 100,000. Trial Registration: N/A.
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Anestesia , Anestesiología , Cirujanos , Femenino , Embarazo , Estados Unidos/epidemiología , Humanos , Recursos Humanos , AnestesiólogosRESUMEN
INTRODUCTION: Gender-based discrimination (GBD) creates a hostile environment during medical school, affecting students' personal life and academic performance. Little is known about how GBD affects the over 204,000 medical students in Brazil. This study aims to explore the patterns of GBD experienced by medical students in Brazil. METHODS: This is a cross-sectional study using an anonymous, Portuguese survey disseminated in June 2021 among Brazilian medical students. The survey was composed of 24 questions to collect data on GBD during medical school, formal methods for reporting GBD, and possible solutions for GBD. RESULTS: Of 953 responses, 748 (78%) were cisgender women, 194 (20%) were cisgender men, and 11 (1%) were from gender minorities. 65% (616/942) of respondents reported experiencing GBD during medical school. Women students experienced GBD more than men (77% versus 22%; P < 0.001). On comparing GBD perpetrator roles, both women (82%, 470/574) and men (64%, 27/42) reported the highest rate of GBD by faculty members. The occurrence of GBD by location differed between women and men. Only 12% (115/953) of respondents reported knowing their institution had a reporting mechanism for GBD. CONCLUSIONS: Most respondents experienced GBD during medical school. Cisgender women experienced GBD more than cisgender men. Perpetrators and location of GBD differed for men and women. Finally, an alarming majority of students did not know how to formally report GBD in their schools. It is imperative to adopt broad policy changes to diminish the rate of GBD and its a consequential burden on medical students.
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Acoso Sexual , Estudiantes de Medicina , Masculino , Humanos , Femenino , Brasil , Estudios Transversales , Sexismo , Encuestas y Cuestionarios , Facultades de MedicinaRESUMEN
OBJECTIVE: This study aims to quantify the number of patent-holding surgeons and determine their specialty demographics. SUMMARY BACKGROUND DATA: The number of intellectual property filings related to surgery has exponentially increased over the past 40 years, yet surgeon inventor status among these inventions remains poorly defined. METHODS: A query of the United States Patent and Trademark Office (USPTO) Patent Full-Text and Image Database was performed over the years 1993 to 2018. Patents related to surgery were defined as surgical devices, implantables, dressings, introducers, and sterilization equipment based on Cooperative Patent Classification (CPC) code. Inventor names were cross-indexed with names of active Fellows in the American College of Surgeons (FACS) as of 2019. Surgeon inventors were identified and differences between specialty and sex were evaluated. RESULTS: A total of 275,260 patents related to surgery were issued over the study period. The number of surgical patents has increased by 462% from 4593 per year to 21,241 per year. A total of 9008 patents were held by a total of 2164 surgeons (4% of FACS). This represents 3.3% of all surgical patents with a mean of 5 patents (range 1-346) per patent-holding surgeon. Specialties with the largest number of patent holders include neurosurgery (9%) and orthopedic surgery (8%). Ninety-seven percent of patent-holding surgeons were male. CONCLUSIONS: 3.3% of patents related to surgery involve a surgeon inventor, and although the number of surgical patents has shown an exponential increase, surgeon involvement in these inventions has grown minimally. Surgical innovation training may offer an opportunity to reduce these discrepancies and increase surgeon involvement as patent holders.
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Neurocirugia , Cirujanos , Masculino , Humanos , Estados Unidos , Femenino , Invenciones , Procedimientos Neuroquirúrgicos , CreatividadRESUMEN
INTRODUCTION: Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil. METHODS: Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated. RESULTS: Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020. CONCLUSIONS: In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.
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Anestesia , Anestesiología , Ortopedia , Médicos Mujeres , Brasil , Femenino , Humanos , MasculinoRESUMEN
INTRODUCTION: Gender-based discrimination (GBD) creates a hostile environment that can affect medical students. Mentorship has been recognized as a mitigating factor for GBD. We aimed to investigate the impacts of GBD on career selection and well-being of medical students in Brazil and to explore access to mentorship among these students. METHODS: A cross-sectional study was performed using an anonymous survey in Portuguese. The survey was distributed in June 2021 to students enrolled in Brazilian medical schools. It contained 24 questions, including demographics, episodes of GBD experienced by responders and their impact on professional and personal life, and mentorship access. RESULTS: Of 953 respondents, 748 (78%) were cisgender women, 194 (20%) cisgender men, and 11 nonbinary (1%). Sixty-six percent (625/953) of students reported experiencing GBD, with cisgender women and nonbinary being more likely to experience it than cisgender men (P < 0.001). Responders who experiences GBD report moderate to severe impact on career satisfaction (40%, 250/624), safety (68%, 427/624), self-confidence (68%, 426/624), well-being (57%, 357/625), and burnout (62%, 389/625). Cisgender women were more likely to report these effects than men counterparts (P < 0.01). Only 21% of respondents (201/953) had mentors in their medical schools. CONCLUSIONS: Our findings demonstrate that GBD is widespread among Brazilian medical students affecting their personal and professional lives, and most of them do not have access to a mentor. There is an urgent need to increase access to mentors who could mitigate the adverse effects of GBD and help develop a diverse and inclusive medical workforce.
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Mentores , Estudiantes de Medicina , Brasil , Selección de Profesión , Estudios Transversales , Femenino , Humanos , Masculino , Sexismo , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To reduce preventable deaths of newborns and children, the United Nations set a target rate per 1000 live births of 12 for neonatal mortality (NMR) and 25 for under-5 mortality (U5MR). The purpose of this paper is to define the minimum surgical workforce needed to meet these targets and evaluate the relative impact of increasing surgeon, anesthesia, and obstetrician (SAO) density on reducing child mortality. METHODS: We conducted a cross-sectional study of 192 countries to define the association between surgical workforce density and U5MR as well as NMR using unadjusted and adjusted B-spline regression, adjusting for common non-surgical causes of childhood mortality. We used these models to estimate the minimum surgical workforce to meet the sustainable development goals (SDGs) for U5MR and NMR and marginal effects plots to determine over which range of SAO densities the largest impact is seen as countries scale-up SAO workforce. RESULTS: We found that increased SAO density is associated with decreased U5MR and NMR (P < 0.05), adjusting for common non-surgical causes of child mortality. A minimum SAO density of 10 providers per 100,000 population (95% CI: 7-13) is associated with an U5MR of < 25 per 1000 live births. A minimum SAO density of 12 (95% CI: 9-20) is associated with an NMR of < 12 per 1000 live births. The maximum decrease in U5MR, on the basis of our adjusted B-spline model, occurs from 0 to 20 SAO per 100,000 population. The maximum decrease in NMR based on our adjusted B-spline model occurs up from 0 to 18 SAO, with additional decrease seen up to 80 SAO. CONCLUSIONS: Scale-up of the surgical workforce to 12 SAO per 100,000 population may help health systems meet the SDG goals for childhood mortality rates. Increases in up to 80 SAO/100,000 continue to offer mortality benefit for neonates and would help to achieve the SDGs for neonatal mortality reduction.
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Mortalidad Infantil , Desarrollo Sostenible , Niño , Mortalidad del Niño , Estudios Transversales , Humanos , Lactante , Recién Nacido , Recursos HumanosRESUMEN
BACKGROUND: Race and ethnicity are associated with disparate trauma outcomes. This study seeks to characterize accuracy of trauma registry classification of patient race and ethnicity and to identify factors associated with misclassification. METHODS: A prospective observational study of patients admitted to an urban Level 1 trauma center was conducted over a 6-mo period. Race and ethnicity data recorded in the trauma registry were compared to patients' self-identifying data obtained through in-person interviews. Logistic regression determined rates of discordant race and ethnicity between trauma registry and patient self-identification processes, and identified factors independently associated with misclassification. RESULTS: A total of 444 patients were recruited. 98 (22%) self-identified as Hispanic/Latino. 45 patients self-identifying as Hispanic (45.9%) had inaccurately recorded ethnicity in the trauma registry. There was an increased odds of ethnicity misclassification in younger patients (OR 0.97, P < 0.01) and Spanish-only speakers (OR 11.80, P < 0.001). A decreased odds was found in males (OR 0.43, P < 0.05). No factors increased odds of racial misclassification, while dual English/Spanish speakers (OR 0.05, P < 0.01) wereas found to have decreased odds. Neither ethnicity nor race misclassification was associated with clinical variables. New racial self-identification was observed with 75% of patients who self-identified ethnically as Hispanic also self-identifying racially as Hispanic. CONCLUSIONS: Hispanic trauma patients have racial and ethnic misclassifications regardless of clinical status. Racial and ethnic identification is not sufficiently captured by current standardized questionnaires. Accuracy of hospital level racial data is important for local and national policies to address trauma disparities.
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Etnicidad , Hispánicos o Latinos , Admisión del Paciente , Centros Traumatológicos , Heridas y Lesiones , Humanos , Masculino , Estudios Prospectivos , Encuestas y Cuestionarios , Heridas y Lesiones/etnología , Centros Traumatológicos/estadística & datos numéricosRESUMEN
BACKGROUND: Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. METHODS: To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20-40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. RESULTS: Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p < 0.01 for each model). When accounting for concomitant increases in surgical volume, scale-up of the surgical workforce to 20-40 SAO/100,000 could potentially prevent between 262,709 (95% CI 229,643-295,434) and 519,629 (465,046-573,919) under 5 deaths annually. The majority (61%) of deaths averted would be neonatal deaths. CONCLUSION: Scale up of surgical workforce may substantially decrease childhood mortality rates around the world. Our analysis suggests that scale-up of surgical delivery through increase in the SAO workforce could prevent over 500,000 children from dying before the age of 5 annually. This would represent significant progress toward meeting global child mortality reduction targets.
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Mortalidad del Niño , Países en Desarrollo , Niño , Femenino , Salud Global , Humanos , Lactante , Mortalidad Infantil , Recién Nacido , Recursos HumanosRESUMEN
BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.
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Servicio de Anestesia en Hospital , Anestesiólogos/provisión & distribución , Anestesiología/instrumentación , Anestésicos/provisión & distribución , Necesidades y Demandas de Servicios de Salud , Hospitales Públicos , Evaluación de Necesidades , Estudios Transversales , Guatemala , Encuestas de Atención de la Salud , Disparidades en Atención de Salud , HumanosRESUMEN
BACKGROUND: Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. MATERIAL AND METHODS: A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. RESULTS: A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. CONCLUSION: In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.
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Lista de Verificación , Heridas y Lesiones , Adolescente , Brasil , Niño , Hospitales , Humanos , Estudios Prospectivos , Centros Traumatológicos , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/epidemiología , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality. METHODS: The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesarean section, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure. RESULTS: 4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%, r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesarean section (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = - 0.53, p = .004), but not for emergency cesarean section or open, long bone fractures POMR. CONCLUSION: Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.
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Cesárea/mortalidad , Fracturas Abiertas/cirugía , Laparotomía/mortalidad , Periodo Perioperatorio/mortalidad , Causas de Muerte , Urgencias Médicas , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , EmbarazoRESUMEN
Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners - individuals and institutions - help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.
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Política de Salud , Internacionalidad , Procedimientos Quirúrgicos Operativos , Anestesia , Femenino , Humanos , Procedimientos Quirúrgicos Obstétricos , EmbarazoRESUMEN
INTRODUCTION: Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS: The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS: 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION: Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE: III.
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Bases de Datos Factuales , Unidades de Cuidados Intensivos , Tiempo de Internación , Hígado , Bazo , Heridas no Penetrantes , Humanos , Heridas no Penetrantes/terapia , Niño , Bazo/lesiones , Adolescente , Masculino , Femenino , Preescolar , Hígado/lesiones , Lactante , Estados Unidos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Estudios Retrospectivos , Traumatismos Abdominales/terapia , Centros Traumatológicos/estadística & datos numéricos , Puntaje de Gravedad del TraumatismoRESUMEN
The World Health Organization (WHO) recently launched the Global Initiative for Childhood Cancer (GICC), with the goal of attaining at least 60% cancer survival for children worldwide by the year 2030. This study aims to describe the global patterns of childhood cancer survival in 2019 to help guide progress in attaining the GICC target goal. In this ecological, cross-sectional study, we used 5-year net childhood cancer survival (2015-2019) data from a prior micro-modeling study from 197 countries and territories. Descriptive statistics were used to analyze the patterns of overall childhood cancer survival and survival for each of the six cancer tracer diagnoses as proposed by the GICC. We used hot spot analysis to identify geographic clusters of high and low cancer survival. Most high-income countries reached at least 60% (92%, n = 59/64), net childhood cancer survival at baseline. No lower-middle-income or low-income country reached at least 60% overall cancer survival at baseline. The South-East Asia region had the highest proportion of countries that did not achieve at least 60% survival at baseline (100%, n = 10/10), followed by the African region (98%, n = 49/50). For each cancer tracer diagnosis, we found the highest number of countries that have achieved at least 60% survival was for Burkitt lymphoma (44%, n = 87/197) followed by acute lymphocytic leukemia (41%, n = 80/197).Hot spot analysis showed the highest overall survival was concentrated in North America and Europe, while the lowest survival was concentrated in Sub-Saharan Africa and South-East Asia.A majority of LMICs had not reached the WHO target goal of at least 60% survival from childhood cancer at baseline in 2019, with variable success for the six childhood cancer tracer diagnoses of the GICC. These findings provide baseline assessment of individual country performance to help achieve the GICC goal of 60% overall cancer survival globally by 2030.
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OBJECTIVE: While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies. DESIGN: We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia. RESULTS: Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed 'human resources and training' and 'infrastructure', four addressed 'service delivery', three addressed 'governance and financing', two included 'research, evaluation and quality improvement', and one NSOAP addressed 'equipment and supplies' and 'advocacy and awareness'. CONCLUSIONS: Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.
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Anestesia Obstétrica , Atención a la Salud , Embarazo , Femenino , Humanos , Niño , Zambia , Políticas , Evaluación de NecesidadesRESUMEN
INTRODUCTION: Pediatric surgery applicants are increasingly pursuing research in non-traditional fields including surgical innovation. This study aims to evaluate the relative value that pediatric surgeons involved in fellow selection place on innovation experience compared to traditional research. METHODS: A cross-sectional web-based survey of American Pediatric Surgical Association members involved in the selection of pediatric surgical fellows was conducted. Respondents reported their own innovation experience and were asked to identify valuable traits of applicants who completed an innovation fellowship. They rated the value of traditional research metrics including publications, presentations, and advanced degrees compared to patents and other innovation-related metrics. Comparisons were made between those with and without innovation experience with respect to gender, years in practice, and institutional role. RESULTS: One hundred thirty respondents were involved in pediatric surgery fellow selection. Innovation work was felt to be equal to or more valuable than basic science by 75% of respondents (84% vs. clinical/outcomes, 93% vs. other non-traditional, 72% vs. other clinical fellowships). Commonly cited concerns included "fewer publications" (21%) and "preoccupation with financial reward" (19%). The most valuable innovation-related metrics were "developing a novel surgical procedure" (67%) and "developing a novel device" (58%). When asked if the respondent would advise a junior resident to pursue an innovation fellowship, 49% would, 9% would not, and 43% were unsure. Seventeen percent expressed concern for match success. CONCLUSION: Innovation experience is generally viewed positively by pediatric surgeons involved in fellow selection. However, applicants and mentors would benefit from focusing on traditional academic outputs to ensure competitiveness. TYPE OF STUDY: Cross-sectional observational study. LEVEL OF EVIDENCE: III.
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Internado y Residencia , Especialidades Quirúrgicas , Cirujanos , Niño , Humanos , Estados Unidos , Becas , Estudios Transversales , Actitud , Encuestas y CuestionariosRESUMEN
BACKGROUND: During COVID-19, medical schools transitioned to online learning as an emergency response to deliver their education programmes. This multi-country study compared the methods by which medical schools worldwide restructured the delivery of medical education during the pandemic. METHODS: This multi-country, cross-sectional study was performed using an internet-based survey distributed to medical students in multiple languages in November 2020. RESULTS: A total of 1,746 responses were received from 79 countries. Most respondents reported that their institution stopped in-person lectures, ranging from 74% in low-income countries (LICs) to 93% in upper-middle-income countries. While only 36% of respondents reported that their medical school used online learning before the pandemic, 93% reported using online learning after the pandemic started. Of students enrolled in clinical rotations, 89% reported that their rotations were paused during the pandemic. Online learning replaced in-person clinical rotations for 32% of respondents from LICs versus 55% from high-income countries (HICs). Forty-three per cent of students from LICs reported that their internet connection was insufficient for online learning, compared to 11% in HICs. CONCLUSIONS: The transition to online learning due to COVID-19 impacted medical education worldwide. However, this impact varied among countries of different income levels, with students from LICs and lower middle income countries facing greater challenges in accessing online medical education opportunities while in-person learning was halted. Specific policies and resources are needed to ensure equitable access to online learning for medical students in all countries, regardless of socioeconomic status.
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COVID-19 , Educación a Distancia , Educación Médica , Estudiantes de Medicina , Humanos , COVID-19/epidemiología , Educación a Distancia/métodos , Estudios Transversales , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence. METHODS: A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates. RESULTS: One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score. CONCLUSIONS: This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.
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BACKGROUND: Surgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV). METHODS: Pediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated. RESULTS: Twelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was -11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures. CONCLUSIONS: Surgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis.