Online medical education: A student survey.

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.

Gender-Based Discrimination Among Medical Students: A Cross-Sectional Study in Brazil.

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.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.

BACKGROUND/PURPOSE: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. METHODS: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. RESULTS: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. CONCLUSION: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. LEVEL OF EVIDENCE: Level III.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study.

OBJECTIVE: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. METHODS: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. RESULTS: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. CONCLUSION: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Gender Discrimination, Career Aspirations, and Access to Mentorship Among Medical Students in Brazil.

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.

Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study.

OBJECTIVES: This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN: The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING: A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS: There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS: The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS: CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.

Acid suppression duration does not alter anastomotic stricture rates after esophageal atresia with distal tracheoesophageal fistula repair: A prospective multi-institutional cohort study.

INTRODUCTION: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation. METHODS: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively. RESULTS: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation. CONCLUSION: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers.

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.

Analysis of authorship trends in vascular surgery demonstrates a sticky surgical floor for women.

OBJECTIVE: Prior research in vascular surgery has identified significant gender disparities in leadership positions, but few data exist regarding gender disparities in vascular publications. This study aims to evaluate authorship trends by gender in the three highest impact factor vascular surgery journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in the European Journal of Vascular and Endovascular Surgery, the Journal of Vascular Surgery, and Annals of Vascular Surgery from 2015 to 2019. The web-based application Genderize used predictive algorithms to classify names of first and last authors as male or female. Statistical analyses regarding trends in authorship were performed using Stata16. RESULTS: A total of 6457 articles were analyzed, with first author gender predicted with >90% confidence in 83% (4889/5796) and last author gender in 88% (5078/5796). Overall, 25% (1223/4889) of articles had women first authors, and 10% (501/5078) had women last authors. From 2015 to 2019, there was a slight increase in the proportion of articles written by women first authors (P = .001), but no increase in the proportion of articles written by women last authors (P = .204). The proportion of articles written by women last authors was lower than the proportion of active women vascular surgeons in 2015 (8% of articles vs 11% of surgeons; P = .015), 2017 (9% of articles vs 13% of surgeons; P < .001), and 2019 (11% of articles vs 15% of practicing surgeons; P < .001). The average number of last-author publications was higher for men (2.35 ± 3.76) than for women (1.62 ± 1.88, P = .001). The proportion of unique authors who were women was less than the proportion of active women vascular surgeons in 2017 (10% unique authors vs 13% surgeons; P = .047), but not in 2015 (9% unique authors vs 11% surgeons; P = .192) or 2019 (13% unique authors vs 15% surgeons; P = .345). Notably, a woman last author was associated with 1.45 higher odds of having a woman first author (95% confidence interval, 1.17-1.79; P = .001). CONCLUSIONS: Over the past 5 years, there has been no significant increase in women last authors among top-tier journals in vascular surgery. Women remain under-represented as last authors in terms of proportion of published articles, but not in terms of proportion of unique authors. Nevertheless, women last authors are more likely to publish with women first authors, indicating the importance of women-led mentorship in achieving publication gender equity. Support for women surgeons through grants and promotions is essential not only for advancing last authorship gender equity, but for advancing junior faculty and trainee academic careers.

Is authorship by women in Brazilian academic surgery increasing? A five-year retrospective analysis.

Women remain underrepresented in 80% of Brazilian surgical specialties, however, women representation within the Brazilian academic surgical literature remains unknown. This study aims to evaluate the gender distribution of first and last authors in Brazilian surgical journals. All publications between 2015 and 2019 from the five Brazilian surgical journals with the highest impact factor were reviewed. The first and last authors' names were extracted from each article and a predictive algorithm was used to classify the gender of each author. Authors were further classified by surgical field and geographic region to investigate patterns of female authorship among journals, specialties, and region over the study period. Multivariable logistic regression was then used to identify factors independently associated with female authorship. 1844 articles were analyzed; 23% (426/1844) articles had female first authors, and 20% (348/1748) had female last authors. Acta Cirúrgica Brasileira was observed to have the highest rates for both first and last female authors (37%, 138/371; 26%, 95/370)) and Revista Brasileira de Ortopedia (9%, 48/542; 10%, 54/522) had the lowest rates. Papers with a woman senior author were twice as likely to have a woman first author (OR 1.98, 95% CI 1.51-2.58, p≤0.01). Women's representation in medicine is increasing in Brazil, yet women remain underrepresented as the first and last authors in the Brazilian surgical literature. Our results highlight the importance of senior women mentorship in academic surgery and demonstrate that promoting female surgeon senior authorship through academic and financial support will positively impact the number of female first authors.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study / Avaliação da capacidade cirúrgica do estado do Amazonas utilizando uma ferramenta de avaliação cirúrgica. Estudo transversal

ABSTRACT Objective: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. Methods: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. Results: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. Conclusion: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

RESUMO Objetivo: o Brasil é um país com cobertura universal de saúde, mas o acesso à cirurgia entre populações remotas permanece pouco estudado. Este estudo avalia a capacidade cirúrgica em hospitais que servem populações rurais no estado do Amazonas, Brasil, por meio de avaliações aprofundadas das instalações. Métodos: foi realizada avaliação estratificada randomizada transversal de hospitais que relataram prestar assistência cirúrgica de julho de 2016 a março de 2017. A Ferramenta de Avaliação Cirúrgica desenvolvida pela Organização Mundial da Saúde e o Programa de Cirurgia Global e Mudança Social da Harvard Medical School foi administrada em hospitais remotos, incluindo uma revisão retrospectiva de registros médicos e livros cirúrgicos. Resultados: 18 hospitais foram pesquisados. Três hospitais (16,6%) não tinham salas cirúrgicas e 12 (66%) tinham 1-2. 14 hospitais (77,8%) relataram que a oximetria de pulso estava "sempre presente" e seis hospitais (33%) nunca têm um anestesiologista disponível. A anestesia inalatória estava disponível em 12 hospitais (66,7%), 77,8% não possuíam dispositivo de ventilação mecânica. Em média, 257 procedimentos por 100.000 foram realizados. 10 hospitais (55,6%) não possuem unidade de recuperação anestésica. Para as regiões de abrangência dos 18 hospitais, com população de 497.492 habitantes, a densidade média de força de trabalho cirúrgica, anestesista e obstétrica foi de 6,4. Conclusão: as populações que vivem em áreas rurais no Brasil enfrentam disparidades significativas no acesso à assistência cirúrgica, apesar da presença de cobertura universal de saúde. O desenvolvimento de um plano estadual de cirurgia é necessário para garantir acesso à assistência cirúrgica às populações rurais.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study.

BACKGROUND: The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. METHODS: Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. FINDINGS: Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663-1,523,995) total operations, 161,321 (95%CI 37,468-395,478) emergent operations, and 928,758 (95%CI 675,202-1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. INTERPRETATION: Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Intravenous cephalosporin versus non-cephalosporin-based prophylaxis to prevent surgical site infections in colorectal surgery patients: A systematic review and meta-analysis.

BACKGROUND: Surgical site infection (SSI) is common in colorectal surgery patients and associated with morbidity and mortality. Guidelines recommend preoperative intravenous antimicrobial prophylaxis with aerobic and anaerobic coverage to reduce SSI risk. Cephalosporin based prophylaxis (CBP) regimens are recommended as first-line prophylaxis, and non-cephalosporin based are recommended as alternative prophylaxis (AP). We evaluate the efficacy of CBP versus AP in preventing surgical site infections in colorectal surgery patients. METHODS: A systematic review and meta-analysis was conducted of studies published between 2005 and 2020 in MEDLINE and Web of Science. Studies were excluded if intravenous antimicrobial prophylaxis was not administered, or if oral and intravenous prophylaxis were routinely co-administered. Heterogeneity was reported using the Q-statistic and I2-statistic. Publication bias was evaluated using a funnel plot and Egger test for small study effects. Statistical significance was defined as a two-sided p < 0.05. RESULTS: 11 studies met inclusion criteria. AP was not associated with increased SSI risk at 30 days compared to CBP (OR 1.01, 95% CI 0.91, 1.13; OR < 1 favors AP). There was no effect size variability in subgroup analysis comparing higher-to lower-quality studies (I2 = 99%, P = 0.17). Subgroup analysis by publication year approached a significant difference in effect size between studies published prior to 2014 and later than 2014 (I2 = 99%, P = 0.06). CONCLUSIONS: Meta-analysis of 11 studies of SSI risk in adult colorectal surgery patients suggest that SSI risk is similar for patients receiving CBP or AP, subgroup analysis of studies published since 2014 suggest increased SSI risk with AP compared to CBP.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital.

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.

Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and Middle-Income Countries: A Global Study.

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.

Empowering Surgeons, Anesthesiologists, and Obstetricians to Incorporate Environmental Sustainability in the Operating Room.

OBJECTIVE: We review the existing research on environmentally sustainable surgical practices to enable SAO to advocate for improved environmental sustainability in operating rooms across the country. SUMMARY OF BACKGROUND DATA: Climate change refers to the impact of greenhouse gases emitted as a byproduct of human activities, trapped within our atmosphere and resulting in hotter and more variable climate patterns.1 As of 2013, the US healthcare industry was responsible for 9.8% of the country's emissions2; if it were itself a nation, US healthcare would rank 13th globally in emissions.3 As one of the most energy-intensive and wasteful areas of the hospital, ORs drive this trend. ORs are 3 to 6 times more energy intensive than clinical wards.4 Further, ORs and labor/delivery suites produce 50%-70% of waste across the hospital.5,6 Due to the adverse health impacts of climate change, the Lancet Climate Change Commission (2009) declared climate change "the biggest global health threat of the 21st century" and predicted it would exacerbate existing health disparities for minority groups, children and low socioeconomic patients.7. METHODS/RESULTS: We provide a comprehensive narrative review of published efforts to improve environmental sustainability in the OR while simultaneously achieving cost-savings, and highlight resources for clinicians interested in pursuing this work. CONCLUSION: Climate change adversely impacts patient health, and disproportionately impacts the most vulnerable patients. SAO contribute to the problem through their resource-intensive work in the OR and are uniquely positioned to lead efforts to improve the environmental sustainability of the OR.