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INTRODUCTION: Simulation-based training often fails to meet the needs of low- and middle-income countries with limited access to high-cost models. We built on an existing surgical simulation curriculum for medical students in Rwanda and assessed students' experience. METHODS: Based on a contextual simulation-based education curriculum that was piloted in 2022, our team designed and delivered an intensive week-long surgical simulation course for medical students. We increased interactive clinical scenarios using high-fidelity mannequins, improved and added benchtop models for training, and incorporated a new postcourse assessment of students' experiences using a survey on the first Kirkpatrick level to determine sessions with the highest utility. Modules included informed consent, preoperative patient preparation, trauma simulations, and procedural skills. The final day focused on integrating and applying skills learned throughout the week in an interactive circuit. RESULTS: Thirty-six students participated in the 5-d simulation course and 24 completed an end of course survey. When asked about their exposure to simulation prior to the course, 20/24 (83%) students reported "a lot" and 4/24 (17%) reported "a little", 24/24 (100%) strongly agreed that simulation is a valuable educational tool and 23/24 (96%) felt that the week enhanced their knowledge and skills to "a great extent". The modules with the highest self-rated level of engagement were the interactive trauma simulations, knot-tying and suturing practice and competition, and a model-based session on cutaneous lesions. The lowest ranked session was the interactive circuit on integrated skills. CONCLUSIONS: Implementing a locally-informed and locally-sourced surgical simulation curriculum is feasible and effectively engages medical students in low-income settings.
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BACKGROUND: Armed conflicts pose a burden on health care services. We sought to assess the surgical capacity and responses of nonmilitary and nongovernmental humanitarian responders in armed conflicts through proxy indicators to identify strategies to address surgical needs. METHODS: We searched 6 databases for articles/studies from January 1, 2013, to March 10, 2023. We included articles detailing the surgical capacity of nonmilitary, nongovernmental organizations operating in armed conflicts. We defined surgical capacity through indicators including the type and number of surgical procedures; number of operating rooms, surgical beds, surgeons, anesthesiologists, and surgical equipment; and type of anesthesia employed. RESULTS: We screened 2,187 abstracts and 279 full texts and included 30 articles/studies. Our sample covered 23 countries and 17 surgical specialties. Most publications focused on surgical capacity assessment (63.3%, 19/30) and surgical and clinical outcomes (63.3%, 19/30). Most articles/studies reported surgical capacity indicators at the hospital (56.7%, 17/30) and multinational (26.7%, 8/30) levels. The number (86.7%, 26/30) and type (76.7%, 23/30) of surgical procedures performed were the most commonly reported. More than one half of the articles (53.3%, 16/30) described strategies to meet surgical needs in armed conflicts. Most strategies addressed information management (68.8%, 11/16), health workforce (62.5%, 10/16), and service delivery (62.5%, 10/16). CONCLUSION: This review collated common approaches for strengthening health care services in armed conflicts. Several articles emphasized strategies for improving information management, service delivery, and workforce capacity. Hence, we call for standardization of response protocols and multilevel collaborations to maintain or even scale up surgical capacity in armed conflicts.
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Conflictos Armados , Humanos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Altruismo , Quirófanos , Cirujanos/estadística & datos numéricosRESUMEN
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.
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COVID-19 , Humanos , COVID-19/epidemiología , SARS-CoV-2 , Servicio de Cirugía en Hospital/organización & administración , Planificación en Desastres/organización & administración , Servicio de Anestesia en Hospital/organización & administración , PandemiasRESUMEN
Background: Accessibility to surgical services can impact earthquake preparedness and response. We aimed to estimate the population with timely access to surgical care in Guerrero, a Mexican state with high tectonic activity, and identify populations at risk in the event of an earthquake. Methods: We conducted an ecological study using open government data. We extracted data from Guerrero municipalities regarding their earthquake risk, social vulnerability, social inequality, marginalisation, and resilience indices. The latest combines municipalities' resistance to unexpected events and capacity to maintain optimal functionality without immediate federal or international support. Geographical coordinates of active public and private surgical facilities in Guerrero were combined with ancillary spatial data on roads and municipalities' population density to estimate population coverage within 30-min and 1-h driving time to surgical facilities in Redivis. We built an ordered beta regression model for each driving time estimate. Findings: We identified 25 public and 16 private facilities capable of providing surgical care in Guerrero. The population with access to facilities with surgical capacity within 30 min and 1-h driving times were 48.4% and 69.1%, respectively. We found that municipalities with very high levels of earthquake risk, social vulnerability, social inequality, and marginalisation, and very low levels of resilience had decreased coverage. In the multivariable analysis, the resilience index was statistically significant only for the 30-min model, with an effect size of 0.524 (95% CI 0.082, 1.089). Interpretation: Access to surgical care remains unequally distributed in Guerrero municipalities at the highest risk for earthquakes. Municipalities' resilience was the most significant predictor of higher surgical care coverage in 30-min driving time. Our study provides insights on how surgical system strengthening can enhance earthquake emergency disaster planning. Funding: No funding.
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The present work explores a controversy surrounding gender equity in surgical residency programs, particularly focusing on the Stanford University and University of Washington (UW) General Surgery Residency cohorts. While the Stanford cohort, which consisted mostly of women, faced criticism from nonmedical audiences claiming that gender was prioritized over qualifications, the all-male radiology residents received less attention and fewer criticisms. The article highlights the double standards and challenges the notion of meritocracy. It discusses the gender and racial disparities in surgical residency programs, emphasizing the need for diversity and inclusion. The presence of diverse female representation is seen as a valuable asset that brings compassion, teamwork, and inclusive leadership to the field. The article calls for active support from institutions, male allies, and transparency in collecting applicant demographic data to address biases and promote gender diversity in surgery.
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Internado y Residencia , Radiología , Humanos , Masculino , Femenino , Estados Unidos , Grupos RacialesRESUMEN
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.
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INTRODUCTION: Merkel cell carcinoma (MCC) is an aggressive cutaneous cancer that frequently compromises the lymph nodes (LN) and distal organs. We sought to describe clinical and demographic characteristics of affected patients, analyze risk factors for LN compromise, metastasis, and death, and evaluate their impact on survival. MATERIALS AND METHODS: Patients with MCC were retrieved from the SEER database. Demographic, clinical and treatment data were analyzed. Logistic and Cox proportional hazard regression were used to analyze risk factors. Survival analysis was done with the Kaplan-Meier method. RESULTS: A total of 2010 patients were included, among which 288 (14.33%) had distant metastases at diagnosis. LN involvement occurred in 45.8% and 20.1% of patients with and without distant metastasis, respectively. Males were more likely to present LN compromise (OR = 1.33, p<0.001). Tumors >10 mm showed a significantly higher risk for LN involvement and distant metastasis, with those >20 mm showing the highest risk (OR = 2.76 p<0.001 and OR = 8.88 p<0.001 respectively). Location of the tumor in the trunk was a protective factor for overall death (OR = 0.27), while LN compromise was a risk factor (OR = 3.12). Only history of previous malignancy significantly affected disease-specific death (OR = 0.32, p = 0.01). One-year survival was 79.7% and 38.2% for patients with regional LN disease and distant metastasis, respectively. CONCLUSION: MCC is an aggressive cancer with high rates of LN involvement and distant metastases. Male gender and tumor size were risk factors for regional LN and metastatic disease. Tumor location in the trunk decrease the risk of overall death, while LN involvement increased it.
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Carcinoma de Células de Merkel , Neoplasias Cutáneas , Humanos , Masculino , Carcinoma de Células de Merkel/terapia , Carcinoma de Células de Merkel/patología , Modelos de Riesgos Proporcionales , Ganglios Linfáticos/patología , Escisión del Ganglio Linfático , Neoplasias Cutáneas/patología , Neoplasias Cutáneas/terapiaRESUMEN
Bones are the third most common site of metastatic disease. Treatment is rarely curative; rather, it seeks to control disease progression and palliate symptoms. Imaging evaluation of a patient with symptoms of metastatic bone disease should begin with plain X-rays. Further imaging consists of a combination of (PET)-CT scan and bone scintigraphy. We recommend performing a biopsy after imaging workup has been conducted. Metastatic bone disease is managed with a combination of systemic treatment, radiotherapy (RT), and surgery. External beam RT (EBRT) is used for pain control and postoperatively after fracture stabilization. Single-fraction and multiple-fractions schemes are equally effective achieving pain control. Adequate assessment of fracture risk should guide the decision to stabilize an impending fracture. Despite low specificity, plain X-rays are the first tool to determine risk of impending fractures. CT scan offers a higher positive predictive value and can add diagnostic value. Surgical management depends on the patient's characteristics, tumor type, and location of fracture/bone stock. Fixation options include plate and screw fixation, intramedullary (IM) nailing, and endoprostheses. Despite widespread use, the need for prophylactic stabilization of the entire femur should be individually analyzed in each patient due to higher complication rates of long stems.
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Introduction: Dedifferentiated chondrosarcoma (DDC) is an aggressive osseous neoplasm with a dismal prognosis. Treatment commonly involves limb-salvage surgery or amputation. In patients with appendicular DDC, we sought to describe demographic, clinical and treatment characteristics (1), analyze risk factors for metastasis (2) and overall death (3), and assess survival rates by treatment (4). Materials and methods: Two-hundred-and-five patients from the SEER Database were included in our analysis. Demographic, clinical and treatment variables were analyzed. Multivariate regression was performed to identify risk factors. Survival analysis was performed using the Kaplan-Meier method. Results: Fifty-one (24.9 %) of the patients included presented metastasis at diagnosis. The most common locations were the lungs, other sites, and bone. Surgery to the primary site was more common in patients without metastasis (94.2 %) than those with (78.2 %); limb-salvage procedures were more common than amputations. Tumors >8 cm (T2) and those discontinuous (T3) were more likely to present metastasis at diagnosis (OR = 2.54, p = 0.043 and OR = 7.4, p = 0.008, respectively). Female gender was found to be a protective factor for overall death on crude analysis (OR = 0.33, p = 0.019). Metastases to sites other than the lungs (M1b) had the highest risk of overall death (OR = 49, p = 0.01). Combination of surgery and chemotherapy showed a trend towards higher overall survival in non-metastatic patients (p = 0.1069 and p = 0.1703). Conclusions: Appendicular DDC displays a high metastatic rate and low survival rates. The most common procedure is a limb-salvage surgery. Tumor size increases the risk of presenting metastases at diagnosis and female gender is a protective factor against death.
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Aims: In chronic osteomyelitis-derived squamous cell carcinoma, what are the demographic and clinical variables, risk factors associated with worse outcomes, and results of treatment modalities used? Methods: A systematic review was performed using PubMed and EMBASE. Articles were evaluated for inclusion and exclusion criteria, and for quality analysis. PRISMA guidelines were applied. Demographic and clinical data and therapeutic approaches were presented narratively and in descriptive statistics registered at PROSPERO. Results: Most patients were male (40/49), trauma was the most common etiology (27/36), and about half of all SCC were in the tibia (25/48). Amputation was the main definitive treatment (42/47). Adjuvant treatments were not analyzed. Well-differentiated SCC accounted for 58.3% (21/36) of all tumors. Bone invasion was described in 82.8% (24/29); recurrence, in 7.7% (3/39); and metastasis, in 7.7% (3/39). Recurrence and metastasis occurred more frequently when bone invasion was present (p = 0.578 and p = 0.646, respectively). SCC with lymph node involvement showed a higher tendency to metastasize (p = 0.377). Compared with limb salvage, amputation was associated with a tendency for less recurrence (p = 0.312) and longer survival (p = 0.219). Conclusions: COM-derived SCC mostly occurs after trauma and is usually located in the tibia. Bone invasion is common, and patients predominantly undergo amputation. This treatment is associated with a trend toward higher survival, compared to limb salvage.
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â¢: In soft-tissue sarcomas (STSs), the use of positron emission tomography-computed tomography (PET-CT) through a standardized uptake value reduction rate correlates well with histopathological response to neoadjuvant treatment and survival. â¢: PET-CT has shown a better sensitivity to diagnose systemic involvement compared with magnetic resonance imaging and CT; therefore, it has an important role in detecting recurrent systemic disease. However, delaying the use of PET-CT scan, to differentiate tumor recurrence from benign fluorodeoxyglucose uptake changes after surgical treatment and radiotherapy, is essential. â¢: PET-CT limitations such as difficult differentiation between benign inflammatory and malignant processes, inefficient discrimination between benign soft-tissue tumors and STSs, and low sensitivity when evaluating small pulmonary metastases must be of special consideration.
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Sarcoma , Neoplasias de los Tejidos Blandos , Humanos , Tomografía Computarizada por Tomografía de Emisión de Positrones , Terapia Neoadyuvante , Tomografía de Emisión de Positrones/métodos , Recurrencia Local de Neoplasia , Sarcoma/diagnóstico por imagen , Sarcoma/terapia , Neoplasias de los Tejidos Blandos/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/terapiaRESUMEN
In light of global environmental crises and the need for sustainable development, the fields of public health and environmental sciences have become increasingly interrelated. Both fields require interdisciplinary thinking and global solutions, which is largely directed by scientific progress documented in peer-reviewed journals. Journal editors play a critical role in coordinating and shaping what is accepted as scientific knowledge. Previous research has demonstrated a lack of diversity in the gender and geographic representation of editors across scientific disciplines. This study aimed to explore the diversity of journal editorial boards publishing in environmental science and public health. The Clarivate Journal Citation Reports database was used to identify journals classified as Public, Environmental, and Occupational (PEO) Health, Environmental Studies, or Environmental Sciences. Current EB members were identified from each journal's publicly available website between 1 March and 31 May 2021. Individuals' names, editorial board roles, institutional affiliations, geographic locations (city, country), and inferred gender were collected. Binomial 95% confidence intervals were calculated for the proportions of interest. Pearson correlations with false discovery rate adjustment were used to assess the correlation between journal-based indicators and editorial board characteristics. Linear regression and logistic regression models were fitted to further assess the relationship between gender presence, low- and middle-income country (LMIC) presence and several journal and editor-based indicators. After identifying 628 unique journals and excluding discontinued or unavailable journals, 615 journal editorial boards were included. In-depth analysis was conducted on 591 journals with complete gender and geographic data for their 27,772 editors. Overall, the majority of editors were men (65.9%), followed by women (32.9%) and non-binary/other gender minorities (0.05%). 75.5% journal editorial boards (n = 446) were composed of a majority of men (>55% men), whilst only 13.2% (n = 78) demonstrated gender parity (between 45-55% women/gender minorities). Journals categorized as PEO Health had the most gender diversity. Furthermore, 84% of editors (n = 23,280) were based in high-income countries and only 2.5% of journals (n = 15) demonstrated economic parity in their editorial boards (between 45-55% editors from LMICs). Geographically, the majority of editors' institutions were based in the United Nations (UN) Western Europe and Other region (76.9%), with 35.2% of editors (n = 9,761) coming solely from the United States and 8.6% (n = 2,373) solely from the United Kingdom. None of the editors-in-chief and only 27 editors in total were women based in low-income countries. Through the examination of journal editorial boards, this study exposes the glaring lack of diversity in editorial boards in environmental science and public health, explores the power dynamics affecting the creation and dissemination of knowledge, and proposes concrete actions to remedy these structural inequities in order to inform more equitable, just and impactful knowledge creation.
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Objective: To know the most frequent acute cardiovascular complications in a Peruvian population of oncologic patients. Materials and methods: Retrospective, descriptive study of oncologic patients treated at Clinica Delgado between January 2014 and December 2019, from which the subgroup with the seven most prevalent cancers at the national level was selected according to information from Globocan 2018. Additionally, we evaluated the epidemiology of patients with cardiovascular complications that conditioned their hospitalization or were detected during this, calculating their cardiovascular risk according to Hermann and SCORE risk scales. Results: Forty-four patients had complications; 27 (61.4%) were hospitalized due to acute cardiovascular causes. The mean age of this subgroup was 69.88 years (SD 12.77), and 22 (81.5%) were older than 60 years. Fourteen (51.9%) were male. According to the Hermann scale, 33.3% had intermediate-risk and 14.9% had a high or very high risk. According to the SCORE scale, 62.97% had an intermediate-risk and 7.40% high risk. The most common acute cardiovascular complications were deep vein thrombosis and ischemic stroke (66.65%). One patient (3.7%) reported previous cardiovascular disease. Four patients (14.8%) had a fatal outcome during hospitalization. The median length of hospitalization was five days. Conclusions: We present the cases of acute cardiovascular complications in a population of oncologic patients and their vascular risk according to Hermann and SCORE scales. The most common complications were deep vein thrombosis (48.14%), stroke (18.51%), and myocardial infarction (14.81%).
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Based on the pathophysiological characterization of COVID-19, initial studies suggested the use of tocilizumab (TCZ), a recombinant humanized monoclonal antibody of the immunoglobulin G1 class, for management of the cytokine storm witnessed in severe cases. Thus, we decided to present a case series of 18 patients with severe COVID-19 treated with TCZ at our hospital. Our results coincide with the fact that the routine use of TCZ in severe COVID-19 is not robustly supported. We believe that the efficacy and safety of this drug and other related molecules should be validated in large randomized clinical trials.
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INTRODUCTION: Brain metastases (BM) in soft-tissue sarcomas (STS) is associated with poor prognosis. This large population analysis presents (1) demographic and clinical variables of these patients, (2) potential risk factors, (3) impact of BM on overall survival, and (4) treatment strategies. METHODS: Patients with STS and BM were identified from the Surveillance, Epidemiology, and End Results database. Demographic and clinical variables, as well as treatment modalities, were analyzed. Overall 5-year survival was calculated using the Kaplan-Meier method, and the survival difference was assessed using the log-rank test. A multivariate analysis was performed using the Cox proportional hazard regression to determine the risk factors. RESULTS: Twenty-two patients (22/8,433) with STS presented BM at diagnosis. A multivariate analysis showed that women and American Indians/Alaska Natives had a greater risk of presenting BM. The most common histological subtype to metastasize to the brain was alveolar soft part sarcoma (4/22). In 54.5% of patients with BM, the tumor had also metastasized to the lung, although having synchronous bone, liver, and lung metastases showed the greatest increase in risk for presenting BM (odd ratio [OR] = 1,857.7, confidence interval [CI] 95%, 88.4 to 3,9046.6, P < 0.0001). Individually, bone metastasis increased the risk of presenting BM the most (OR = 205.0, CI 95%, 30.5 to 1,379.6, P < 0.0001). The mean survival of patients with BM was 10.22 months. The standard treatment approach included surgery, radiation therapy, and chemotherapy. CONCLUSION: BM in patients with STS represents an infrequent but lethal event. Women and American Indians/Alaska Natives are at a higher risk of presenting BM, as well as patients with synchronous metastases. Patients are mainly managed with systemic therapy.
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Neoplasias Encefálicas , Sarcoma de Parte Blanda Alveolar , Neoplasias de los Tejidos Blandos , Neoplasias Encefálicas/terapia , Estudios de Cohortes , Femenino , Humanos , PronósticoRESUMEN
AIMS: The objective of this study is to analyze how the impact of Diabetes Mellitus [DM] in patients with COVID-19 varies according to altitudinal gradient. METHODS: We obtained 1,280,806 records from adult patients with COVID-19 and DM to analyze the probability of COVID-19, development of COVID-19 pneumonia, hospitalization, intubation, admission to the Intensive Care Unit [ICU] and case-fatality rates [CFR]. Variables were controlled by age, sex and altitude of residence to calculate adjusted prevalence and prevalence ratios. RESULTS: Patients with DM had a 21.8% higher prevalence of COVID-19 and an additional 120.2% higher prevalence of COVID-19 pneumonia. The adjusted prevalence was also higher for these outcomes as well as for hospitalization, intubation and ICU admission. COVID-19 and pneumonia patients with DM had a 97.0% and 19.4% higher CFR, respectively. With increasing altitudes, the probability of being a confirmed COVID-19 case and the development of pneumonia decreased along CFR for patients with and without DM. However, COVID-19 patients with DM were more likely to require intubation when residing at high altitude. CONCLUSIONS: The study suggests that patients with DM have a higher probability of being a confirmed COVID-19 case and developing pneumonia. Higher altitude had a protective relationship against SARS-CoV-2 infection; however, it may be associated with more severe cases in patients with and without DM. High altitude decreases CFR for all COVID-19 patients. Our work also shows that women are less affected than men regardless of altitude.